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Home My WebLink About20120041.tiff Esther Gesick From: Esther Gesick Sent: Thursday, December 29, 2011 10:17 AM To: Pam Imler-Cooper Cc: Esther Gesick Subject: RE: Appeal of Board of Commissioners decision Pam, I did also receive confirmation from the County Attorney that any party may appeal the Commissioners' decision; however, it must be filed within 30 days from the action date(December 21st.) Esther E. Gesick Deputy Clerk to the Board/Office Manager 1150 O Street(P.O. Box 758'Greeley, CO 80632 tel: (970)336-7215 X4226 W EL0. u Confidentiality Notice:This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication.Any disclosure,copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Pam Imler-Cooper [mailto:dreamwriter9@gmail.com] Sent: Wednesday, December 28, 2011 4:47 PM To: Esther Gesick Cc: Arlen Siert; Dean Felton; Dolf Veit; Greg Brand; Joe & Lori Harrison; Jolene &Lynn Johns; Pam Imler-Cooper; Pat& April Thorpe; Roray Alguessev; Sherry Been; Steve Ceplius; Wade Subject: Re: Appeal of Board of Commissioners decision Thank you so very much for your attention to our issue, Esther. All of us appreciate the information you've provided. We may not like the Board's decision, but at least we know what steps to take in order to appeal. For that, we thank you very much. Happy New Year, Pam Cooper On Wed, Dec 28, 2011 at 3:22 PM, Esther Gesick<egesick@co.weld.co.us> wrote: Hello Pam, t- 2012-0041 curi Zimint r c.a.-�-cchJ 1 AZ /4/9,5 /- 2 4t O)2 I'm sending you this message in response to a call I received earlier today from Sherry Been. As I indicated to her on the phone, both the applicant or the public may appeal a decision of the Commissioners to the District Court. The County Attorney indicated the party in opposition to the Board's decision has the right to obtain private legal counsel who may advise them on the appropriate process for contesting the decision. Also, as a follow-up on timing of when I may have the minutes for the 21st completed - I have one more hearing to type from December 7th and have completed the regular business from the 12th and will be moving forward to items from the 14th later this week. Happy New Year! Esther E. Gesick Deputy Clerk to the Board/Office Manager 1150 O StreetIP.O. Box 758IGreeley, CO 80632 tel: (970) 336-7215 X4226 $ k3ii WOOat 1/4V CCU) TV u Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. 2 Esther Gesick From: Pam Imler-Cooper[dreamwriter9@gmail.com] Sent: Thursday, December 22, 2011 10:15 AM To: Esther Gesick Subject: Re: USR11-0021 Good Morning Esther, Thank you so VERY much for getting back to me. Although the outcome is not what we had hoped, we now have the information we need to appeal the Board's decision. You went above and beyond for me/us and I truly appreciate your assistance with our concerns. Have a very Merry Christmas! Pam On Thu, Dec 22, 2011 at 10:05 AM, Esther Gesick<gesick@co.weld.co.us> wrote: Good Morning Pam, I am writing to let you know the Anadarko/Kerr-McGee Gathering, LLC, application was approved yesterday afternoon; we finished up around 3:30 p.m. It's unfortunate more people couldn't have stayed around to hear the applicant's presentation and very forthright answers to some pretty tough and direct questions from the Board based on your public testimony. Attached is the Draft Resolution, minus the changes the Board made, but at least you have the base document. I will say some of the additional requirements are: - A specific Noise Abatement Plan which was reviewed in depth during the applicants presentation - Lighting plan with direct instruction to do the shielding immediately - Posting of the Complaint Hotline number on the perimeter fence signage - Maintaining a list of interested parties to keep them apprised of future construction activities— noise study dates and results—etc. - The applicant agreed to landscaping/screening, as appropriate, and in compliance with Oil and Gas Commission Regulations - Commitment to Safety measures of new company, as fire was under different company management 1 - A general understanding that the County and State are both very aware of the non-compliance issues and will be watching and enforcing, as necessary, to bring current conditions into compliance, while moving forward with new technology and sound abatement to replace the old noisy equipment - Project Manager, Joe Sanchez, estimated the new work to be completed by June 2012. I hope all of this gives you a sense of the final outcome, in lieu of the minutes at this time. I will also pass along the Board did commend all of the neighborhood for participating and providing the them with solid testimony, which helped them make an informed decision. They also urged area residents to be diligent in calling the Complaint Hotline and not only complaining, but striving to offer constructive and realistic suggestions for improvement. More importantly, now that everyone is aware of who is involved and how to make contact, they urged the applicant and the area residents to work at forming a working relationship going forward. Again, I apologize in advance for the anticipated delay in preparing the final Resolution and Minutes; however, please feel free to call or e-mail requesting a status on my progress, or if you have any further questions. I hope you all enjoy a Very Merry Christmas! Esther E. Gesick Deputy Clerk to the Board/Office Manager /150 O StreetIP.O. Box 758IGreeley, CO 80632 tel: (970) 336-7215 X4226 tiol loll ate' w ElC0C OLNTr u: Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. 2 Esther Gesick From: Esther Gesick Sent: Tuesday, January 03, 2012 8:13 AM To: Lauren Light Cc: Barbara Kirkmeyer; Sean Conway; William Garcia; Dave Long; Douglas Rademacher; Bruce Barker; Esther Gesick Subject: FW: Noise at Oil And Gas on road 10 (USR11-0021 -Anadarko/Kerr-McGee Gathering - Hearing 12/21/11) Lauren, Please see the noise complaint below and let me know if you need anything further. I've copied the Board on this complaint and it will also be added to the case file. Thanks! Esther E. Gesick Deputy Clerk to the Board/Office Manager 1150 O Street P.O. Box 758'Greeley, CO 80632 tel: (970)336-7215 X4226 rn's lJ' Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Jolene Johns [mailto:ilpioelineCa)aol.com] Sent: Saturday, December 31, 2011 4:40 PM To: Esther Gesick Subject: Noise at Oil And Gas on road 10 Dear Councilmen, It seems like ever since the hearing the noise levels have been higher. Can you have someone check on this.Thank you. Jolene Johns 8690 Weld County Road 10 Ft. Lupton, CO ObYrynkui /- 9— c20)a- apt a- noi-k1 1 PA_/yg3 AGREEMENT BETWEEN KERR-MCGEE GATHERING, LLC, AND WELD COUNTY. COLORADO, TO ALLOW THE RELEASE OF BUILDING PERMITS PRIOR TO RECORDING THE PLAT FOR SECOND AMENDED USE BY SPECIAL REVIEW PERMIT NO. USR11-0021 4/4 THIS AGREEMENT ("Agreement") is made and entered into this (6) day of January, 2012, by the County of Weld, State of Colorado, acting through the Weld County Department of Planning Services (collectively referred to as the "County"), and KERR-MCGEE GATHERING, LLC ("Kerr-McGee"), whose address is 1099 18`h Street, Suite 1800, Denver, Colorado 80202- 1918. RECITALS WHEREAS, Kerr-McGee is the owner of real property described as Part of the NW4 of Section 15, LOIN, R67W of the 6th P.M., Weld County, Colorado (the "Property"), and commonly known as 3988 Weld County Road 19; and WHEREAS, Kerr-McGee has applied and received approval for a second Amended Site Specific Development Plan and Use by Special Review Permit To Add 8 Additional Compressor Units As Well As 2 Separators, 2 Slug Catchers, A Back Up Generator And Other Equipment under Case# USRI 1-0021 on December 21, 2011, and WHEREAS, a standard condition of Use by Special Review Permits is that no building or electrical permits be issued on the property until the Special Review plat is ready to be recorded in the office of the Weld County Clerk and Recorder, and WHEREAS, Kerr-McGee is aware of certain risks associated with the early release of building permits that includes, but is not limited to the appeal process available pursuant to C.R.C.P. 106, which may be filed anytime up to thirty (30) days following the date of mailing the Board of County Commissioner of Weld County Resolution of approval, and WHEREAS, Kerr-McGee, has applied for building permits for six (6) compressor units under building permit numbers OLG11-00744, OLG11-00752, OLG11-00753, OLG11-00754, OLGI 1-00755, and OLG11-00756, and WHEREAS, Kerr-McGee is requesting that building permits OLG11-00744, OLG11- 00752, O1,G1 1-00753, OLG11-00754, OLG11-00755 and OLG11-00756 be issued prior to the submittal of the USRI 1-0021 plat for recording and prior to January 1 s`, 2012. NOW, THEREFORE, in consideration of the foregoing, County consents to the release of building permits OLG11-00744, OLG11-00752, OLGI1-00753, OLG11-00754, OLG11- 00755 and OLGI1-00756. In return for the early release of the building permits by the County, Kerr-McGee, agrees to abide by the following terms and conditions: Page 1 of 2 C 6Thatikn cotes-o3 yl 1�- 2DI- PC_lyg3 1. The above recitals are incorporated herein by reference as though set forth herein verbatim. 2. Kerr-McGee shall have sixty (60) days from the date of the Board of County Commissioners approval of USR11-0021 to complete the conditions of approval and have a plat ready for recording. 3. Prior to grading the applicant must submit acceptable calculations and sizing of the water quality feature and indicate its location on the draft plat. 4. Prior to the movement and transport of compressor station equipment, the Kerr-McGee shall receive a special transport permit from the Weld County Department of Public Works for overweight/oversized vehicles. 5. Prior to the movement and transport of compressor station equipment, Kerr-McGee a traffic control plan shall be submitted to and approved by the Weld County Department of Public Works. 6. Building permits shall not be finaled and the installed equipment shall not be operated until all USR11-0021 conditions of approval have been completed and the plat has been submitted for recording. 7. In the event the plat is not submitted for recording within sixty (60) days as required in Section 2 of this Agreement, Kerr-McGee shall have thirty (30) days to remove all buildings and equipment that do not conform to the Weld County Code and to return the Property to the condition it was in prior to the execution of this Agreement. Failure to do so within the thirty (30) day period may result in prosecution for violations of the Weld County Code. 8. Failure by Kerr-McGee to adhere to the terms and conditions of this Agreement, as solely determined by the County, may, at the County's sole discretion, result in the termination of this Agreement. In the event this Agreement is so terminated, Kerr-McGee shall have thirty (30) days to remove all buildings and equipment that do not conform to the Weld County Code and to return the Property to the condition it was in prior to the execution of this Agreement. Failure to do so within the thirty (30) day period may result in prosecution for violations of the Weld County Code. Signed this V day of January, 2012. Well County; ep ment of Pk ng Services Kerr-McGee Gather'ng LLC. By: lit�1 V C D By: v2��( �)6*A> Trevor Jin e irector Title: (;'f er l7 ikGa Page 2 of 2 Esther Gesick From: Esther Gesick Sent: Tuesday, January 10, 2012 9:26 AM To: Vince Harris Cc: Lauren Light; Chris Gathman; Rick Behning; Commissioners; Esther Gesick Subject: RE: Oil and gas facility I wouldn't know; however, a contact from a company representative to verify with Ms.Johns would probably clear up the details and open a line of communication as discussed in the hearing. Esther E. Gesick Deputy Clerk to the Board/Office Manager 1150 O Street P.O. Box 758IGreeley, CO 80632 tel: (970)336-7215 X4226 mous ;K Confidentiality Notice:This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged,confidential or otherwise protected from disclosure.If you have received this communication in error,please immediately notify sender by return e-mail and destroy the communication.Any disclosure,copying,distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Vince Harris [mailto:vince@ baselinecoro.com] Sent: Tuesday, January 10, 2012 9:27 AM To: Esther Gesick Cc: Lauren Light; Chris Gathman; Rick Behning Subject: RE: Oil and gas facility I have received this and passed on to Anadarko. Esther—do you know why the original email date stamp time of 5:53pm is different than her explained 1:05am time? Just trying to understand the time that a loud noise was heard to maybe try and track what may have been going on? Best regards, Vince Vincent Harris,AICP Planning Director Baseline Corp 700 12th Street, Suite 220 Golden, Colorado 80401 Tel 303.202.5010 x217 Fax 303.940.9959 www.baselinecorp.com From: Esther Gesick [mailto:egesick@co.weld.co.us] Sent: Tuesday, January 10, 2012 9:06 AM .,/O/ 7" ley/ t'/,daticrvZJ 1 P� V93 /-/e0 -ao'a To: Commissioners Cc: Lauren Light; Chris Gathman; Esther Gesick; ilpipelineaol.com; vince@baselinecorp.com Subject: FW: Oil and gas facility Commissioners: Please see the complaint below. I am also copying the Health and Planning Departments and the applicant's representative, and it will be included as an addition to the case file. Please let me know if you need anything further. Esther E. Gesick Deputy Clerk to the Board/Office Manager 1150 O Street P.O. Box 758IGreeley, CO 80632 tel.: (970) 336-7215 X4226 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Jolene Johns jmailto:ilpipeline@aol.coml Sent: Monday, January 09, 2012 5:53 PM To: Esther Gesick Subject: Oil and gas facility Mrs Councilmen : I would like to report the noise at the oil and gas facility. All day it has been extremely LOUD right now it is 1:05 am and it is still going strong. 2 Esther Gesick From: Esther Gesick Sent: Monday, January 16, 2012 9:20 AM To: forwecooper@gmail.com; dreamwriter9@gmail.com Cc: Bruce Barker; Michelle Martin; Esther Gesick; Sherry Been Subject: FW: USR11-0021 Attachments: CSB_Safety_Bulletin_Final_Embargoed_10_2_09.pdf; CSBFinalReportLittleGeneral.pdf; KleenUrgentRec.pdf; Veolia_Case_Study.pdf; RE: appeal Mr.Cooper, I previously provided correspondence to Pam Cooper and Sherry Been on December 28, 2011, regarding this matter(see attached e-mail titled "Appeal"); however, based on your message below, please allow me to clarify a few items. First, any party may obtain private legal counsel and appeal the decision of the Board of County Commissioners; however,the appeal is made to District Court; not the Board of Adjustment, and must be done within 30 days of the public decision by the Board. Second, I intend to finalize the minutes and Resolution from the hearing this week, if possible; however, filing of an appeal is not contingent upon completion of my typed summary, so do not let that delay your submittal. Third, I understand you are out of town until February 1st; however,the official case file has been available for public inspection since public notice was sent in October, 2011, and the deadline for filing an appeal is January 23, 2012. Any member of the public may come to our office and review the file on your behalf and copies cost$0.25 per page, or I can provide a digital copy of the entire file via e-mail, at a cost of$0.10 per page=$22.50. Lastly,this e-mail and the attachments you provided will also be added to the file and circulated for Commissioner review as a matter of correspondence on the 1/18/12 Agenda. Regards, Esther E. Gesick Deputy Clerk to the Board/Office Manager 1150 0 Street)P.0. Box 7581 Greeley, CO 80632 tel: (970)336-7215 X4226 I.� - -_ F 1y Confidentiality Notice:This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged,confidential or otherwise protected from disclosure.If you have received this communication in error,please immediately notify sender by return e-mail and destroy the communication.Any disclosure,copying,distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Wade Cooper [mailto:forwecooper@gmail.com] Sent: Friday, January 13, 2012 4:09 PM To: Esther Gesick Subject: USR11-0021 Dear Esther, I am writing to you because it is my understanding that the Weld County Code (Article 23) allows an appeal of the Board of Commissioner's decision to the Board of Adjustment within 30 days of their decision. In accordance with this appeal procedure, I am appealing the Board of Commissioner's approval of USR11-0021 to the Board of Adjustment. I have been unable to locate on the Weld County website any information on USR11-0021 since it was apparently approved on Dec. 21, 2011. Ltz-nt : a_.) (201a-004i/ / i '-,9.0.A2. t PL I y93 To properly and completely appeal the Board of Commissioners approval of USR11-0021, Frederick Compressor Station expansion, I would like to review the entire official record for the case. After being able to review the complete official record, I will be more informed to fully address my appeal to the Board of Adjustment. I am currently out of state until Feb. 1st, but would like to arrange a review of its official record sometime after I return. Please let me know if your office can accomodate this request. I am currently appealing the Board of Commissioners approval of USR11-0021 to the Board of Adjustment based on its lack of conformance with Article 23-2-260.A.7. as presented below: 7. A statement which explains that there is adequate provision for the protection of the health, safety and welfare of the inhabitants of the NEIGHBORHOOD and the COUNTY. This nonconformance is predicated on the site expansion resulting in large quantities (greater than 10,000 pounds) of flammable gases/vapors/liquids on site such that the site would no longer be exempt from both OSHA's Process Safety Management standard (29 CFR 1910.119) and the EPA's Risk Management Program standard (40 CFR Part 68). These two standards are recognized in process safety as hazardous facilities which pose additional safety and health risks to surrounding communities. The standards were developed to help mitigate the fire and explosion hazards associated with such large quantities of highly hazardous chemicals, but they alone do not prevent such catastrophic events from occurring. The fact that the large quantities of flammable gases/vapors/liquids pose additional safety and health risks (including hydrogen sulfide gas and overpressures due to explosions)to surrounding inhabitants demonstrates that the proposed expansion will adversely affect the health, safety and welfare of the surrounding inhabitants. Below are presented numerous flammable gases/vapor/liquid incidents investigated by the Chemical Safety Board (CSB) in recent years. They are by no means conclusive of all incidents, but details some of the more catastrophic incidents investigated by the CSB. Please consider this information. 1. A propane tank explosion at Leprino Foods in Greeley CO. on Friday, Dec. 23, 2011 (just 2 days after our public hearing where I warned the Board of Commissioners about the fire/explosion hazard of the proposed expansion). No injuries, but it shook buildings and possibly damaged some in the surrounding community. The whole article is not available without a subscription. http://www.greelevtribune.com/article/20111223/NE W S/712239989/1078 2. Conagra Slim Jim plant http://www.csb.gov/newsroom/detail.aspx?nid=300&SID=0&pg=1&F All=y 3. Board investigators said they have identified a number of similar gas purging accidents in recent years, including an explosion at a Michigan power plant in 1999 that killed 6 and caused $1 billion in property damage and an explosion in 2008 at a San Diego hotel that injured 14. 4. NDK America, Rockford IL -Note a member of the public was killed by debris which was thrown over 300 yards. http://www.csb.gov/newsroom/detail.aspx?nid=297&SID=0&pg=1&F All=y 5. Kleen Energy Plant , Middletown, CT. Feb. 7, 2010. Six killed, 50 injured. Purging pipelines with natural gas 2 See attachment. 6. Silver Eagle Refinery, Woods Cross, UT , 11/17/09- hydrogen gas explosion damaged over 100 off-site homes. http://www.csb.gov/newsroom/detail.aspx?nid=296&SID=0&pg=1&F All=y 7. Safety message by CSB about how pressure vessels without proper safety safeguards can be catastrophic. Urges jurisdictions throughout the US to adopt the ASME Pressure Vessel Code. Colorado does not exercise enforcement of the code. The compressor receivers, slug catchers, and separators as well as some storage tanks are pressure vessels (i.e., operate at pressures above 15 psig). http://www.csb.gov/newsroom/detail.aspx?nid=293&SID=0&pg=1&F All=y 8. Barton Solvents, Des Moines, IL, Sept 2008, fire and explosion of flammable solvents due to improper bonding and grounding. Similar to what can happen at the storage vessels at the Frederick Compressor Station. http://www.csb.gov/newsroom/detail.aspx?nid=45&SID-0&pg=1&F All=y 9. Valero Refinery, Sunray, TX July 2008. Propane release fire and explosion. http://www.csb.gov/newsroom/detail.aspx?nid=41&SID=0&pg=1&F InvestigationId=12 10. Veolia Environmental, Carrollton, OH May 4, 2009, Flammable vapor fire and explosion, damaged 20 offsite buildings. see attachment. 11. Little General Store, Ghent WV, Jan 30, 2007. Propane leak fire and explosion. Leveled the store, damaged nearby vehicles, Killed 4, injured 6. See attachment. These are just some of the many major incidents demonstrating that the large quantities of flammable gases, vapors, and liquids, such as at the proposed compressor station, can have catastrophic damages, even to offsite residences/buildings. Wade E. Cooper, PE, CSP 3225 County Rd 19 Fort Lupton, CO 80621 3 Esther Gesick From: Esther Gesick Sent: Monday, January 16, 2012 8:35 AM To: Sherry Been Cc: Esther Gesick; dreamwriter9@gmail.com; Bruce Barker; Michelle Martin Subject: RE: appeal Attachments: RE: Appeal of Board of Commissioners decision Sherry, Please see the attached prior correspondence regarding your questions. As for status on the case, I have completed the regular 9:00 board meeting minutes and documentation, and one of the three land use hearings from the 21st, which just leaves one other case and the case you are interested in,which I will be working on starting today. I will forward a copy of the Resolution and minutes as soon as they are complete. Esther E. Gesick Deputy Clerk to the Board/Office Manager 1150 O Street(P.O. Box 7581 Greeley, CO 80632 tel: (970)336-7215 X4226 Confidentiality Notice:This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged,confidential or otherwise protected from disclosure.If you have received this communication in error,please immediately notify sender by return e-mail and destroy the communication.Any disclosure,copying,distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Sherry Been [mailto:wereafrogCalvahoo.com] Sent: Friday, January 13, 2012 8:45 PM To: Esther Gesick Subject: appeal Hi Esther, Several of the residents that live around the approved gas expansion would like to appeal the decision to allow the expansion. Could you please send me information as to whom we appeal to. You had stated that we have 60 days. Is that the case or is it only 30. If you could contact me at 303-902-9262, that would be great. Thank you Sherry Been 1 Esther Gesick From: Esther Gesick Sent: Thursday, December 29, 2011 10:17 AM To: Pam Imler-Cooper Cc: Esther Gesick Subject: RE: Appeal of Board of Commissioners decision Pam, I did also receive confirmation from the County Attorney that any party may appeal the Commissioners' decision; however, it must be filed within 30 days from the action date (December 21st.) Esther E. Gesick Deputy Clerk to the Board/Office Manager 1150 O Street(P.O. Box 758(Greeley, CO 80632 tel: (970)336-7215 X4226 184i ]oii ? CO W El`d'EO V/NTr u Confidentiality Notice:This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication.Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Pam Imler-Cooper [mailto:dreamwriter9Calamail.com] Sent: Wednesday, December 28, 2011 4:47 PM To: Esther Gesick Cc: Arlen Siert; Dean Felton; Dolf Veit; Greg Brand; Joe &Lori Harrison; Jolene &Lynn Johns; Pam Imler-Cooper; Pat & April Thorpe; Roray Alguessev; Sherry Been; Steve Ceplius; Wade Subject: Re: Appeal of Board of Commissioners decision Thank you so very much for your attention to our issue, Esther. All of us appreciate the information you've provided. We may not like the Board's decision, but at least we know what steps to take in order to appeal. For that, we thank you very much. Happy New Year, Pam Cooper On Wed, Dec 28, 2011 at 3:22 PM, Esther Gesick <eaesick(aco.weld.co.us> wrote: Hello Pam, t I'm sending you this message in response to a call I received earlier today from Sherry Been. As I indicated to her on the phone, both the applicant or the public may appeal a decision of the Commissioners to the District Court. The County Attorney indicated the party in opposition to the Board's decision has the right to obtain private legal counsel who may advise them on the appropriate process for contesting the decision. Also, as a follow-up on timing of when I may have the minutes for the 21st completed - I have one more hearing to type from December 7th and have completed the regular business from the 12th and will be moving forward to items from the 14th later this week. Happy New Year! Esther E. Gesick Deputy Clerk to the Board/Office Manager 1150 O Street P.O. Box 758IGreeley, CO 80632 tel: (970) 336-7215 X4226 let ' l0II W Ei`&/COUN TY u Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. 2 • l 4\ . . - - a , , - : - :--, 4-:-7' .,� - t _ . Mt ' . .... Bf t3 o �teA ate. -..moo .�� _ ! `,;I , ` ;�. S __ __ ., • A . � _.e ._ it,. s�:a� Safa Bu11etin '� _. • y U.S. Chemical Safety and Hazard Investigation Board September 2009 Dangers of Purging Gas Piping into Buildings No. 2009-12-I-NC When new fuel gas piping is put into service — or when one of two methods: (a) fuel gas is used to directly displace existing piping is returned to service after interruptions — the air, or (b) inert gas is used to displace the air and then it is typically necessary to purge the lines of air.' U.S. fuel fuel gas is used to displace the inert gas. With this Safety gas safety codes require that new piping installations be Bulletin, the U.S. Chemical Safety Board (CSB) draws pressure-tested with air or an inert gas prior to initial attention to serious dangers that can arise during fuel gas operation, and this activity requires purging during the purging operations and highlights five key lessons the introduction of natural gas.2 Purging is commonly done by agency recommends for improving safety in the workplace. t 'Y it, is r. j_ r , - i 4 _ - k:41 Who's at Risk. . . - S�• • •.e Personnel who manage, \ k a install, maintain, repair, • - inspect, or place into L. .,� operation fuel gas piping 71• ...„,s,„„„( �► `` and equipment. including: SI Ai i \ • Plumbers P- r -• • Gas installers �!! ,ti f ~' I t -J N - • Maintenance workers _ _ , \ \ • a --r- = t. Ili • Contract supervisors --- - • • Industrial facility ' - .. �• R managers y'` r - ;- . ,_ tea. .- r The ConAgra Slim Jim plant in Garner, North Carolina, where unsafe gas purging caused an explosion in June 2009 that killed three workers and sent 71 to the hospital. 1 National Fuel Gas Code, NFPA 54, ANSI Z223.1 defines a piping purge as "to free a gas conduit of air or gas, or a mixture of gas and air," at 54-15 (2009 Ed.). The National Fire Protection Association (NFPA) develops widely recognized consensus fire protection codes and standards. Another widely recognized family of fire protection codes is published by the International Code Council which includes the International Fuel Gas Code (2009 Ed.). Both codes address safety guidance and requirements for the installation and operation of fuel gas piping and equipment. 2 National Fuel Gas Code, NFPA 54, ANSI Z223.1 at 54-61 to 63 (2009 Ed.); the International Fuel Gas Code at 68 (2006 Ed.). The fuel gas codes require that piping beyond specified lengths be purged with an inert gas based upon the nominal pipe size. CSB • Dangers of Purging Gas Piping into Buildings 1 � , llitain MI i pi �_l Ulan isal , I / lipp ,3iii ih. t• At, d . , . Vs /A i i •„..1 1 - ,0 1 i I i il la -- i .4 _ _ �. r I • f \ `f t . li . ...ear. -mfrs. isZuter; ii 1 I , gir • -a . * Y Interior of ConAgra facility following structural collapse. Aerial views of ConAgra facility after explosion. KEY LESSONS 1 . Purging new or existing gas piping into buildings 3. Never rely on odor alone to detect releases of fuel gases. can be highly hazardous due to the possible An odorant' is typically added to fuel gases, such as accumulation of gas above the lower explosive limit natural gas and propane, to warn workers and (LEL)3 and the associated danger of fire and explosion. consumers of releases. However, the perception of Wherever practicable, directly vent purged gases to a odor is highly subjective and varies from one person safe location outdoors, away from people and ignition to another. People also become desensitized to odor sources. This can be done using a temporary hose or during prolonged exposures. Additionally, new gas piping or permanently installed vent pipes, depending pipes and containers can react with or otherwise on the facility design. remove the odorant, an effect known as "odor fade." 2. Purging indoors should only be done in limited 4. Always use combustible gas detectors' to monitor circumstances where purging outdoors is not the gas concentration during purging operations. practicable. In such cases: To provide the most accurate information about • nonessential personnel should be evacuated; combustible gas levels, sampling should be conducted frequently or continuously at appropriate locations.' • all ignition sources should be controlled or eliminated; • ventilation should be adequate to maintain the gas S. Ensure personnel involved in gas purging operations concentration well below the lower explosive limit at are fully trained and knowledgeable about safe gas all times. venting practices, the proper use of gas detectors, and the danger of relying on the sense of smell alone to detect gas releases. Include training on the problem of odor fade in new gas piping systems. 3 LEL, also known as the Lower Flammable Limit (LFL), is defined as "that concentration of a combustible material in air below which ignition will not occur." Recommended Practice for Handling Releases of Flammable and Combustible Liquids and Gases, NFPA 329 (2005). 4 Natural gas is primarily composed of methane, an odorless and colorless gas. In order to heighten an individual's ability to detect natural gas, small quantities of odorant are added. T-butyl mercaptan (typically described as having a "skunk-like" odor), is one such odorant. 5 Combustible gas detectors measure combustible/flammable gas concentration in the atmosphere, which is indicated on the device as a percentage of the lower explosive limit (LEL). 6 The evaluation of appropriate locations for combustible gas monitoring should include consideration of the purge location, characteristics of the gas (lighter or heavier than air), stratification or mixing of the gas, and existing ventilation. See the International Society for Automation (ISA) RP 12.13, Recommended Practice for the Installation, Operation, and Maintenance of Combustible Gas Detection Instruments (2003) and the American Petroleum Institute (API) 2009, Safe Welding, Cutting, and Hot Work Practices in the Petroleum and Petrochemical Industries (2002). CSB • Dangers of Purging Gas Piping into Buildings 2 GAS PURGING LED TO 2009 EXPLOSION AT CONAGRA SLIM JIM FACTORY On June 9, 2009, a major natural gas explosion heavily On the day of the accident, a worker from Energy damaged the ConAgra Slim Jim meat processing factory Systems Analysts (ESA), the water heater manufacturer, in Garner, North Carolina, just south of Raleigh. Three was attempting to purge the new gas line by using natural workers were crushed to death when a large section of gas to directly displace the air. This was done by removing the building collapsed. The explosion critically burned threaded fittings, creating one or more pipe openings four others and sent a total of 71 people to the hospital near the heater. The worker then opened a quarter-turn including three firefighters who were exposed to toxic valve to control the release of purged gases. ESA reported anhydrous ammonia from the plant's refrigeration system. that it was the company's normal practice to purge fuel Approximately 18,000 pounds of ammonia were released gas piping directly into the room or area when installing to the environment and 100,000 square feet of the plant gas-fired equipment. Code officials and other parties told were damaged. Due to the severity of the structural the CSB that they believe this practice to be common. collapse, there was the potential for numerous additional deaths or serious injuries. The purged fuel gas was vented indoors into the utility room, which was ventilated by an exhaust fan. However, The accident occurred during the installation of a new no assessment was made of the adequacy of the ventila- fuel gas-fired industrial water heater in an interior tion in comparison to the rate of the gas release; whether utility room of the plant. Five days prior to the accident, a dangerous accumulation of flammable gas had occurred a new section of three-inch steel piping — which would could have been most accurately verified by taking direct provide natural gas to the heater — was tied into a measurements inside the utility room using a combustible six-inch natural gas supply line located on the roof gas detector. Because of the difficulties in lighting the water The new natural gas piping ran horizontally over 120 feet heater, personnel perceived that the gas line was not along the roof and then descended into the utility room. effectively purged of air. Therefore, purging was conducted intermittently over a period of up to two-and-a-half hours. _ . ' 4. "dr , � ., M� ,f 1 / „, „, floir- . . , , \v,--... u a a., O i 1 4; Ir. ' r t .ada i 4 • f - ..,, w. 4 N1/4 i • f • Il °.. ) - jr w 4 1 I 1r f”- •'� IIIIII it. �,. - . • TT - . '/ lir ... •. w w t Gas-fired water heater and piping, indicating points where gas was likely released into the building. CSB • Dangers of Purging Gas Piping into Buildings 3 V:. ` t • w' \ t 3 Y f �ji�� . • t 3, . ^,..S. . • - 4,,-2-!'.` 1 - r- : :- .. i. . .• 4 '., � ;-..J. t'�'"'- Jr- - 'a • r • Ih• e JI - y ,L• y 1 ' y 4 ` . ice •`-� .•�rA 1 • Tt:I 1 ., _ - I . , - * ;11;,?•-4.14 -.13t 4! . - • / ,.r••r .. .14 1. CAl :. , • Ale I 1 • tilvtarrittr" . „-• •'+� ' _ � �!•� "! ^ • 44' • .. \ 4. ~~ , — f,_ �. °',`fir,...% ^ -' - b .- _ • A. � •.' ,� - . or— •1., ,•I 4 `+- .;- S '*"' Ira w -. ._'- kr-4"''• :\_ ,a+. � , ) '•e Vif*N- , .. ,,rr�� A��t�y./• - +/� "l �# "' *0E:3. . / •",•" r .••� Jr� :x. -r / a li •r. a �' ;P-P"" 7 •f r 'r ' ' 4• I • -- . . (• ,.�j t �' *.••••••. ,{7T. _ Damage to vegetation hundreds of feet away from the ConAgra plant due to the ammonia release that followed the explosion. ESA and ConAgra employees were aware of the The vicinity of the utility room contained numerous natural gas purging activities inside the utility room. potential ignition sources, including a number of unclas- However, no appropriate combustible gas detectors sified electrical devices. Nonessential personnel were not were used to warn of a potential accumulation of gas in aware of the water heater start-up or instructed to leave the building. Instead personnel relied primarily on the the plant during the gas purging activity. Over 200 people sense of smell to determine when the piping had been who had no role in the installation were in the building effectively purged of air and whether or not an unsafe when the natural gas found an ignition source and release of natural gas occurred. exploded at approximately 11:25 a.m. Some ConAgra employees smelled gas in the packaging Following the June 9 explosion, ConAgra established area; others did not. Personnel who were in and out new procedures for gas purging. These procedures require of the utility room noticed the gas odor, but most were direct venting of purged gases via a hose or piping to not seriously concerned and considered the purging a safe location outdoors, exclusion of personnel and activity to be a normal part of the start-up process. ignition sources from the vicinity of the vent, continous The ESA and ConAgra employees were not aware that air monitoring using combustible gas detectors, and as a result of the purging, a dangerous accumulation of evacuation of nonessential personnel from the facility. natural gas had occurred into the building, exceeding the lower explosive limit. CSB • Dangers of Purging Gas Piping into Buildings 4 SIMILAR INCIDENTS Research conducted by the CSB during its investigation • An explosion that burned two plumbers at a school in of the ConAgra explosion uncovered a number of similar Porterville, California, on November 16, 2005; incidents around the country that involved the purging • An explosion on August 1, 1997, at a fitness center of gas lines, including: in Cary, North Carolina, a short distance from the • An explosion at a 30-story hotel under construction in ConAgra facility, which collapsed the roof, severely San Diego, California, on May 19, 2008, that injured burned two people, and injured four others. 14 workers, including three who suffered severe burns; • An explosion at a hotel in Cheyenne, Wyoming, In addition, OSHA inspection records identify other on August 7, 2007, that severely burned two plumbers; related fuel gas purging incidents have occurred causing deaths and serious injuries. l I i I Explosion seriously L lli 1 ii damages three floors of a Hilton Hotel r • 1 I _ a i t - �' Iii..-A i w , under construction in • Dip 1 +S ` oi' , M �i •,i.i I I San Diego in May 2008, 1 - r , !- I •� l x t tk . 1 , injuring 14. + p43 1. '• � i fit. _ I : Y 1 4.4 j# e' u 4 A v_ft`t,Er IT - .., 1 , a-_.....a Milli so w w l b� �l I -� I -_ . Ai . PHOTO: DIRK HANSEN CONCLUSION As a result of the findings from the ConAgra explosion eliminating ignition sources, and ventilating the space and other recent similar incidents, this Safety Bulletin so that the atmosphere is substantially below the LEL. emphasizes five key lessons to prevent fires and explo- Combustible gas detectors should always be used to sions from purging fuel gas into buildings. These tragic monitor the gas concentration during purging operations incidents can most effectively be prevented by purging — never rely on the sense of smell alone. To effectively flammable gases to a safe location outdoors. Where this implement these practices, workers must be fully trained is not practicable, important safety precautions should and knowledgeable about safe purging practices and the be in place, including removing nonessential personnel, hazard of odor fade in new gas piping systems. The U.S. Chemical Safety and Hazard Investigation Board (CSB) is an independent federal agency charged with investigating industrial chemical accidents. The agency's board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents. including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems. The Board does not issue citations or fines but does make safety recommendations to companies, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Please visit our website, www.csb.gov. No part of the CSB's conclusions, findings, or recommendations may be admitted as evidence or used in any action or suit for damages: see 42 U.S.C. § 7412(r)(6)(G). CSB • Dangers of Purging Gas Piping into Buildings 5 �,, °."•"z°R%y U . S . CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD L J ' O 4 •wn U . x:61 ICS*!.. ...wd0 S.n..' °v INVESTIGATION REPORT LITTLE GENERAL STORE - PROPANE EXPLOSION (Four Killed , Six Injured) • 11, jar \ Ist, . .• I Or- , ii,' \ . ,,4 1, # 7.may- _ - t/ / Ate_ _ ; ur i .. � F -/' ti is 'yy..c�` • .... 4 re � -t�• fir- i • �' 1 .�_, ♦ ___ - - -. wry` _'� '. ` .w r• a *-" .'1,�.p j,y� r - .1.� - • J�.ws ..•cte 2 x+17 5: '+ _ate*. 'a , n 44 1:304116.4 . 0110": 116*' . . . Ira:•.- • .. ' - --' ---• At -1 I ill . �' / _ - _ -1...... jj 1T Photo courtesy of West Virginia State Fire Marshal LITTLE GENERAL STORE , INC . GHENT, WEST VIRGINIA KEY ISSUES: JANUARY 30, 2007 • EMERGENCY EVACUATION • HAZARDOUS MATERIALS INCIDENT TRAINING FOR FIREFIGHTERS • 911 CALL CENTER RESOURCES • PROPANE COMPANY PROCEDURES • PROPANE SERVICE TECHNICIAN TRAINING REPORT NO . 2007-04-I-WV SEPTEMBER 2008 Little General Store September 2008 Contents EXECUTIVE SUMMARY 1 KEY FINDINGS 3 1.0 INTRODUCTION 4 1.1 Summary 4 1.2 Investigative Process 7 1.3 Little General Store, Inc. 8 1.4 Little General Store Propane Suppliers 8 1.5 West Virginia Emergency Service Organizations 9 1.6 Professional and Industry Organizations 12 2.0 INCIDENT DESCRIPTION 13 2.1 Events Preceding January 30, 2007 Explosion 13 2.2 Day of the Incident 14 2.3 Response to the Propane Release 17 3.0 PROPANE INCIDENT FREQUENCY 20 3.1 United States Hazardous Materials Incidents 2001 -2006 20 3.2 Recent Propane Incidents 21 4.0 PROPANE SYSTEM FUNDAMENTALS 22 4.1 Propane Properties 22 4.2 System Features 22 4.3 Propane Standards 24 4.4 Propane Emergency Guidance 25 5.0 INCIDENT AND EMERGENCY RESPONSE ANALYSIS 27 ii Little General Store September 2008 5.1 Liquid Withdrawal Valve 27 5.2 Propane Tank Placement 30 5.3 Propane Service Technician Training and Response 36 5.4 Fire Department Response 41 5.5 911 Emergency Call Center Response 44 6.0 REGULATORY ANALYSIS 46 6.1 Occupational Safety and Health Administration 46 6.2 Environmental Protection Agency 46 6.3 West Virginia Fire Commission 47 7.0 FINDINGS 51 8.0 CAUSES 53 9.0 RECOMMENDATIONS 54 Governor and Legislature of the State of West Virginia 54 West Virginia Fire Commission 54 West Virginia Office of Emergency Medical Services 54 National Fire Protection Association 55 Association of Public-Safety Communications Officials 55 Propane Education and Research Council 55 National Propane Gas Association 56 West Virginia E911 Council 56 Ferrellgas 57 REFERENCES 58 APPENDIX A FERRELLGAS INSTALLATION REVIEWS OF THE INCIDENT TANK 60 APPENDIX B 911 CALL AND INITIAL FIRE DEPARTMENT DISPATCH 63 iii Little General Store September 2008 APPENDIX C RECENT PROPANE INCIDENTS 66 RECENT PROPANE INCIDENTS 67 1.0 PROPANE RELEASE INCIDENTS 67 1.1 Aberdeen,Washington 67 1.2 Lynchburg,Virginia 68 1.3 Bristow,Virginia 70 2.0 PROPANE RELEASE AND FIRE INCIDENTS 72 2.1 Sallis, Mississippi 72 2.2 Danville,Alabama 73 APPENDIX D TABLE OF STATE REQUIREMENTS FOR PROPANE SERVICE TECHNICIANS.75 APPENDIX E UNITED STATES EPA-40 CFR 311 77 iv Little General Store September 2008 List of Figures Figure 1. Aerial photograph of Little General store and surrounding plot. 4 Figure 2. Site plan of Little General Store 6 Figure 3. Liquid withdrawal valve 15 Figure 4. Timeline of initial events 17 Figure 5. Timeline of incident response 19 Figure 6. Typical ASME propane tank. 23 Figure 7. Incident valve plug(Telltale circled) 27 Figure 8. Crack in valve seal 29 Figure 9. Pre-incident photograph of the Ferrellgas tank. 30 List of Tables Table 1. U.S.hazardous materials incidents 2001-2006 20 v Little General Store September 2008 List of Acronyms and Abbreviations ASME American Society of Mechanical Engineers APCO Association of Public-Safety Communications Officials CETP Certified Employee Training Program CFR Code of Federal Regulations CSB U.S. Chemical Safety and Hazard Investigation Board DOT U.S. Department of Transportation EMS Emergency Medical Services EMT Emergency Medical Technician EOC Emergency Operations Center EPA U.S. Environmental Protection Agency FIR Ferrellgas Installation Review HAZWOPER Hazardous Waste Operations and Emergency Response HVAC Heating,Ventilation,and Air Conditioning IC Incident Commander LP Gas Liquefied Petroleum Gas MSDS Material Safety Data Sheet NENA National Emergency Number Association NFIRS National Fire Incident Reporting System NFPA National Fire Protection Association NIMS National Incident Management System NPGA National Propane Gas Association OES Raleigh County Office of Emergency Services OSHA U.S. Occupational Safety and Health Administration PERC Propane Education and Research Council RESA Regional Education Service Agency SCGM Service Center General Manager STARS Safety and Training Administrative Records System WVC West Virginia Code WVCSR West Virginia Code of State Rules vi Little General Store September 2008 Executive Summary On January 30,2007, a propane explosion at the Little General Store in Ghent,West Virginia,killed two emergency responders and two propane service technicians, and injured six others. The explosion leveled the store,destroyed a responding ambulance, and damaged other nearby vehicles. On the day of the incident,a junior propane service technician employed by Appalachian Heating was preparing to transfer liquid propane from an existing tank,owned by Ferrellgas,to a newly installed replacement tank. The existing tank was installed in 1994 directly next to the store's exterior back wall in violation of West Virginia and U.S. Occupational Safety and Health Administration regulations. When the technician removed a plug from the existing tank's liquid withdrawal valve, liquid propane unexpectedly released. For guidance, he called his supervisor, a lead technician, who was offsite delivering propane. During this time propane continued releasing, forming a vapor cloud behind the store. The tank's placement next to the exterior wall and beneath the open roof overhang provided a direct path for the propane to enter the store. About 15 minutes after the release began,the junior technician called 911. A captain from the Ghent Volunteer Fire Department subsequently arrived and ordered the business to close. Little General employees closed the store but remained inside. Additional emergency responders and the lead technician also arrived at the scene. Witnesses reported seeing two responders and the two technicians in the area of the tank, likely inside the propane vapor cloud,minutes before the explosion. Minutes after the emergency responders and lead technician arrived,the propane inside the building ignited. The resulting explosion killed the propane service technicians and two emergency responders who were near the tank. The blast also injured four store employees inside the building as well as two other emergency responders outside the store. 1 Little General Store September 2008 The CSB identified the following causes: 1. The Ferrellgas inspection and audit program did not identify the tank location as a hazard. Consequently,the tank remained against the building for more than 10 years. 2. Appalachian Heating did not formally train the junior technician,and on the day of incident he was working alone. 3. Emergency responders were not trained to recognize the need for immediate evacuation during liquid propane releases. The CSB makes recommendations to the governor and legislature of the State of West Virginia,the West Virginia Fire Commission,the West Virginia Office of Emergency Medical Services,the National Fire Protection Association,the Association of Public-Safety Communications Officials,the Propane Education and Research Council,the National Propane Gas Association,the West Virginia E911 Council, and Ferrellgas. 2 Little General Store September 2008 Key Findings 1. The propane service technicians,emergency responders,and store employees did not evacuate the area as recommended by nationally accepted guidance for propane emergencies. 2. A defect in the existing tank's liquid withdrawal valve caused it to malfunction and remain in an open position. 3. The junior propane service technician who was servicing the tank on the day of the incident had no formal training and did not recognize the defect in the withdrawal valve. He was also working unsupervised,even though he had been on the job for only one and a half months. 4. The placement of the 500-gallon propane tank against the building's exterior back wall provided releasing propane a direct path into the store's interior. 5. The Occupational Safety and Health Administration's and National Fire Protection Association's propane standards require training but do not include curricula,practical exercises,or knowledge evaluation. 6. 911 operators in the United States lack propane emergency guidance to help them collect important information from callers, offer life-saving advice,and convey relevant information to first responders. 7. Firefighters in West Virginia are required to attend a minimum of four hours of hazardous materials emergency response training as part of their initial training sequence,but refresher training is not required. The responding Ghent Volunteer Fire Department captain last attended a hazardous materials response course in 1998. 8. Propane safety and emergency training is voluntary for fire department personnel in West Virginia. None of the responders from the Ghent Volunteer Fire Department had specific propane emergency training. 3 Little General Store September 2008 1.0 Introduction 1.1 Summary At 10:53 am on January 30,2007,a propane explosion leveled the Flat Top Little General Store(Little General)in Ghent,Raleigh County,West Virginia(Figure 1). The explosion killed four and injured six. The dead included two emergency responders(a fire department captain and an emergency medical technician,both from the Ghent Volunteer Fire Department)and two Appalachian Heating propane service technicians. The injured included the four Little General employees who remained inside the store,and two other Ghent Volunteer Fire Department emergency responders. - , 1• m� hl ro"lt : t 111 N.NI.•STa 1 a •. .• N Tank li.Dt A N Map created by,WVGISTC4. k. `4 . . Allii 0 0 019m Figure 1. Aerial photograph of Little General store and surrounding plot. 4 Little General Store September 2008 The morning of the explosion,a junior propane service technician' (junior technician) from Appalachian Heating was preparing to transfer liquid propane from an existing tank owned by Ferrellgas to a newly installed tank'owned by Thompson Gas and Electric Services(Thompson). The Ferrellgas propane tank was installed in 1994 directly against the store's exterior back wall(Figure 2). At about 10:25 am,the junior technician,working alone,removed a threaded plug from the liquid withdrawal valve' on the Ferrellgas tank and liquid propane began flowing uncontrollably. Liquid propane sprayed upward, against the roof overhang,and dense propane gas accumulated at ground level around the tank and the foundation of the building. Over the next 25 minutes,the escaping propane entered the Little General store through openings in the roof overhang. Shortly after the release began,the junior technician called the lead technician to report the release and seek guidance. At 10:40 am,the junior technician called 911 to report the emergency and summon help. A captain and two emergency medical technicians from the Ghent Volunteer Fire Department were the first to arrive, followed by the lead technician and two other emergency responders. Shortly after their arrival,the propane in the store ignited, leveling it and killing two emergency responders(the fire captain and one of the emergency medical technicians)and the two Appalachian Heating propane service technicians. The report discusses the activities of two propane service technicians: a junior technician,who had been performing propane duties for one and a half months,and a lead technician,who had been performing propane duties for one and a half years. "Junior"and"lead"are used in this report to differentiate the technicians' relative experience in propane service. 2 While commonly referred to as tanks,both of these were 500-gallon pressure vessels. The American Society of Mechanical Engineers(ASME)publishes the Boiler and Pressure Vessel code;generally,stationary propane tanks are considered unfired pressure vessels and manufactured in accordance with Section VIII of the code. 3 The liquid withdrawal valve was a RegO Chek-Lok valve model number 7572FC,which is no longer manufactured. Although the RegO name is still used on propane equipment,the company that manufactured this valve is no longer in business. 5 Little General Store September 2008 Fire departments from the neighboring communities of Beckley,Beaver,and Princeton responded to the explosion. Later that day a team from the West Virginia Office of the State Fire Marshal arrived to investigate,assisted by an agent from the U.S. Bureau of Alcohol,Tobacco,Firearms, and Explosives (ATF). Refrigerator Compressors ❑ ❑ Area of Fatalities Walk-in Cooler Walk-in Cooler Office Thom pson Tank #� C 7 F6n --Ferrellgas Tank•`f V V V V V V Restrooms Wooden Floor U Concrete Floor co Sales Counter Pizza Ovens Front Door Figure 2. Site plan of Little General Store. 6 Little General Store September 2008 1.2 Investigative Process The CSB investigation team arrived at the incident scene on January 31. They joined the Incident Command structure,in accordance with the National Incident Management System(NIMS),4 and began on-scene investigation activities. On February 2,2007,Incident Command demobilized after the State Fire Marshal concluded that the incident was not a criminal act. The CSB investigation team remained, and with the help of Little General management,protected and preserved evidence,moving it to a secure storage locker. The team interviewed employees of the companies involved,emergency responders, and officials from the West Virginia Office of the State Fire Marshal; The West Virginia Division of Labor; the Raleigh County Building Department; Regional Education Service Agency(RESA)5 Region I;the United States Fire Academy;the ATF;the Beckley and Beaver, West Virginia Fire Departments;the Occupational Safety and Health Administration(OSHA); the National Fire Protection Association(NFPA); the National Propane Gas Association(NPGA); and the Propane Education and Research Council(PERC). In addition, the CSB tested and examined the valve that released the propane from the Ferrellgas tank. The test protocol included in situ examination and flow testing;removal of the liquid withdrawal valve assembly(valve,tank nozzle, and dip tube);photography and examination of the valve and dip tube, including removal of the dip tube; and dismantling and examination of the valve. 4 NIMS is a comprehensive approach to incident response management that provides a consistent,nationwide template to enable all response entities to work in concert during incidents. Implementation of NIMS is required by the US Department of Homeland Security in accordance with its authority in Homeland Security Presidential Directive 5 "Management of Domestic Incidents." The State Fire Marshal reestablished an incident command system following the explosion. 5 Enacted by the West Virginia Legislature in 1972,RESA provides educational services to schools,including technical,professional,operational,and programmatic services. In addition to school-based programs,RESA coordinates much of West Virginia's professional firefighter training program. 7 Little General Store September 2008 1.3 Little General Store, Inc. Little General Store, Inc. operates 48 convenience stores throughout southern and central West Virginia and western Virginia. The Ghent store was a combination gasoline station and convenience market. At the time of the incident,the Ghent store and three others included pizzerias,which used propane for cooking. 1.4 Little General Store Propane Suppliers 1.4.1 Southern Sun Southern Sun supplied propane to Little General beginning in late 1994. Southern Sun was a family- owned propane,heating oil,and ice supplier located in south central West Virginia. In 1996 Southern Sun sold its propane operations to Ferrellgas, which became the supplier to Little General. 1.4.2 Ferrellgas Ferrellgas,headquartered in Overland Park,Kansas, is the second-largest propane marketer in the United States,with offices and customers in all 50 states. One of Ferrellgas' business strategies is to"expand operations through disciplined acquisitions and internal growth." Since 1986 Ferrellgas has acquired 166 propane distributors throughout the United States. Late in 2006, Little General initiated a change in propane suppliers from Ferrellgas to ThompsonGas Propane Partners. 1.4.3 Thompson Gas and Electric Service, Inc. Thompson is a privately held company that installs commercial and residential propane systems and delivers propane in the eastern and southeastern United States. 8 Little General Store September 2008 1.4.4 Appalachian Heating Appalachian Heating is a family-owned heating,ventilation, air conditioning(HVAC),and plumbing company. Appalachian installs appliances,installs and maintains heating and cooling systems, and installs and repairs plumbing. Appalachian entered into a contract with Thompson in August 2005 to extend its business to include propane supply. 1.4.5 ThompsonGas Propane Partners, LLC ThompsonGas Propane Partners is the limited liability company(LLC)formed between Thompson of Hagerstown, Maryland,and Appalachian Heating of Bradley,West Virginia. Under the agreement forming ThompsonGas Propane Partners, LLC,Appalachian Heating provides personnel to install propane systems and deliver propane; Thompson provides equipment,bulk propane, and technical support. The LLC has no employees. 1.5 West Virginia Emergency Service Organizations 1.5.1 West Virginia State Fire Commission The West Virginia Fire Prevention and Control Act6 of 1975 established the West Virginia State Fire Commission and granted the commission authority to promulgate and establish a state fire code.' The commission established the National Fire Codess as the minimum fire prevention and protection requirements for the state. 6 West Virginia Code Chapter 29,Article 3 "The Fire Prevention and Control Act." 'West Virginia Legislative Rule Title 87,Series 1,"State Fire Code." 8 NFPA publishes the National Fire Codes annually. The National Fire Codes are a collection of all NFPA's standards. 9 Little General Store September 2008 1.5.2 West Virginia State Fire Marshal The West Virginia State Fire Marshal's Office, overseen by the State Fire Commission,has four divisions providing fire protection and regulatory services: regulation and licensing,public education, fire investigation,and regional response. The Fire Marshal enforces the rules of the State Fire Commission throughout West Virginia. Currently,the Fire Marshal's Office employs 12 code inspectors and 11 fire investigators. 1.5.3 Raleigh County Emergency Services An executive group is responsible for emergency services management in Raleigh County,West Virginia. Group membership includes county commissioners;the district attorney; mayors of municipalities;the county sheriff;the Office of Emergency Services(OES); and the county public information officer. Raleigh County emergency services encompass mutual aid management among municipal fire departments(career and volunteer);police; emergency medical transport services;and community-based support agencies. Services are coordinated under a unified command system at the Emergency Operations Center(EOC) located in Beckley. Local municipalities are responsible primarily for emergency response activities within their areas. County resources are available from the OES and coordinated through the EOC when emergencies exceed local response capabilities. The OES develops and maintains the Raleigh County Emergency Plan and manages the county's 911 emergency call center. 1.5.4 Ghent Volunteer Fire Department The Ghent Volunteer Fire Department was incorporated in 1973 and has 28 members providing fire fighting, life protection,and ambulance service to residents in the Ghent area. Salaried Emergency 10 Little General Store September 2008 Medical Technicians(EMTs)are on duty at the fire station 24 hours a day,seven days a week.' All Ghent area emergency 911 calls are routed to the Raleigh County EOC where operators dispatch the appropriate fire or emergency medical service. 1.5.5 West Virginia E911 Council West Virginia established the E911 Council in 1986 to organize and implement the universal 911 emergency telephone number system. The council promotes,researches,plans,educates,develops funding streams, and proposes state legislation to ensure reliable 911 call service operations. Representatives from West Virginia's 55 counties serve on the council, which meets monthly. The council works closely with emergency response industry organizations including the National Emergency Number Association(NENA)and the Association of Public-Safety Communicators Officials (APCO). In addition,the council is involved in activities to promote and fund 911 systems statewide. 1.5.6 West Virginia Office of Emergency Medical Services The West Virginia Office of Emergency Medical Services (EMS)is a division of the West Virginia State Trauma and Emergency Care System, administered by the West Virginia Department of Health and Human Resources. The Office of EMS was legislatively mandated in 1975 and tasked with operating a comprehensive statewide EMS program. It oversees licensing for EMS agencies and training and certification for responders. 9 The Ghent fire department comprises trained volunteer firefighters and paid emergency medical technicians. Many of the emergency medical technicians,including those who responded to the Little General propane release, also serve as volunteer firefighters. 11 Little General Store September 2008 1.6 Professional and Industry Organizations 1.6.1 National Fire Protection Association The NFPA publishes consensus standards applicable to specific industries and activities,including the propane industry and hazardous materials incident response. These standards,while voluntary unless incorporated into state laws or regulations,provide safe practice guidelines for operations in the processes they address. West Virginia adopted the National Fire Codes into the State Fire Code.10 1.6.2 Propane Education and Research Council Congress created the Propane Education and Research Council(PERC) in the Propane Education and Research Act of 1996. PERC's purpose is to promote the safe use of propane energy in the United States. Each gallon of odorized propane sold in the United States is assessed one-half of one cent to fund PERC. PERC estimates revenue of$45,300,000 for the 2009 fiscal year. PERC develops the curriculum for the Certified Employee Training Program(CETP),which is the propane industry's primary training method for service technicians,bulk plant operators,delivery truck drivers,and customer service representatives. 1.6.3 National Propane Gas Association Founded in 1931,the National Propane Gas Association(NPGA)is the trade association representing all propane industry segments. It is located in Washington,D.C., and affiliated with 38 state and regional associations,including the West Virginia Propane Gas Association. The NPGA administers CETP throughout the United States. 10 The CSB determined that the National Fire Codes were adopted by the West Virginia State Fire Marshal prior to 1967,although the exact date is unknown. 12 Little General Store September 2008 2.0 Incident Description 2.1 Events Preceding January 30, 2007 Explosion Significant events preceding the January 30,2007,explosion at the Ghent Little General Store include 1. 1988 - Southern Sun buys the incident tank and places it in propane service. 2. Late 1994- Southern Sun relocates the incident tank from its original installation to the Little General Store in Ghent and installs it against the store's exterior back wall.'' 3. 1996-Ferrellgas buys the Southern Sun propane business and performs a pre-acquisition review of the business and operations, including an inspection of some of Southern Sun's propane systems. 4. 1996 to 2007 -Ferrellgas drivers fill the incident tank about 14 times per year conducting about 140 pre-fill inspections. 5. April and June 2000—Ferrellgas employees perform two Installation Reviews(Appendix A)on the propane system at Little General. 6. August 2005—Thompson Gas and Electric Service, Inc. and Appalachian Heating form the business ThompsonGas Propane Partners, LLC. 11 At the time of the installation,West Virginia and OSHA required 500-gallon propane tanks to be at least 10 feet from buildings;however,Raleigh County had no code enforcement mechanism at that time. 13 Little General Store September 2008 7. September 2006—Appalachian Heating's only propane service technician(the lead technician at the scene of the incident)completes training and becomes fully qualified(in accordance with CETP)to install propane tank systems.12 8. Fall 2006—Little General Store, Inc.,begins changing propane suppliers from Ferrellgas to ThompsonGas Propane Partners. 9. December 2006—Appalachian Heating reassigns an HVAC technician to the propane business (the junior technician at the scene of the incident). 10. January 2007—The two propane service technicians from Appalachian Heating began installing a new Thompson Gas tank and associated equipment at Little General. 2.2 Day of the Incident On the morning of Tuesday,January 30,the two propane service technicians traveled separately to the Little General Store. At around 9:15 am,witnesses observed both of their trucks at the store. According to Appalachian Heating,the day's work plan was to transfer the propane from the existing Ferrellgas tank to the newly installed Thompson tank and place the new propane system in service. By 9:30 am the lead technician had left the store to make a delivery 31 miles northwest of Little General; the junior technician remained alone at the store. For the next hour,the junior technician worked alone while he prepared to transfer propane from the Ferrellgas tank to the Thompson tank. 12 Thompson trained the lead technician on sections 1,2,and 4 of CETP. The lead technician also spent nearly a full year working with experienced personnel from multiple Thompson offices. 14 Little General Store September 2008 Around 10:25 am,the junior technician removed a plugi3 from the liquid withdrawal valve (Figure 3)on the Ferrellgas tank. When he removed the plug,liquid propane unexpectedly began spraying from the valve. 4 Plug VI )'r fr r 4 Valve Body tJ , Valve sealing disk and washer Figure 3. Liquid withdrawal valve. At 10:28 am,the junior technician called14 the lead technician,who was still offsite,to report the problem. In response,at 10:31 am,the lead technician called Thompson technical support for guidance. After the call to technical support,the lead technician called the junior technician twice,most likely to relay the guidance from technical support and to encourage him to call 911. 13 The valve plug has two functions:to prevent a propane leak if the valve seat leaks and to prevent foreign materials'entering the valve mechanism. The withdrawal valve itself is spring-loaded and self-closing and should not leak;however,if it does,a telltale hole drilled through the threaded portion of the plug sprays a small amount of propane giving an early warning of a malfunction prior to completely removing the plug. 14 All telephone calls discussed throughout this report were from cellular phones. 15 Little General Store September 2008 A deliveryman in the store at about 10:30 am told the CSB that he smelled a strong odor and that the store employees' eyes were watering. The Little General cashier,concerned about the odor, went outside to check on the junior technician. The cashier told the CSB that she saw him standing between the tank and his service truck within a dense vapor cloud,1$but that he told her he was"okay." At 10:40 am, the junior technician called 911 to summon help from emergency services(see transcript in Appendix B). He reported to the 911 operator that he had a leaking propane tank at the Little General in Ghent and needed the fire department's assistance to secure the area. The 911 operator collected this information, clarified the location,and ended the call. After the 911 call,the junior technician called the lead technician again. The cashier checked on the junior technician a second time, finding him in the same location between the tank and truck. Figure 4 is an event timeline prior to the lead technician's return. 15 Propane is a colorless gas. A liquid release from a tank forms a dense white cloud of visible propane liquid droplets that then evaporate. 16 Little General Store September 2008 10:51 10:33 10:25 LT calls JT LT arrives Estimated release start time \ 10:31 10:46 JT calls LT LT calls Thompson technical s port 10:37 LT calls JT 1 J n<7 10:32 Incident Commander arrives 10:28 JT calls LT-tloes not connect 1040 JT calls 911 JT calls LT 10:36 LT calls Thompson technical support-does not connect Junior Technician—JT(blue) Lead Technician—LT(green) Figure 4. Timeline of initial events 2.3 Response to the Propane Release After the junior technician's call,Raleigh County Emergency Services dispatched the Ghent Volunteer Fire Department to the Little General (Appendix B). The first to arrive, at about 10:47 am,16 was a captain from the Ghent Volunteer Fire Department. The captain assumed the role of incident commander(IC)in accordance with Ghent Volunteer Fire Department guidelines.l7 16 As no record of precisely what time the captain arrived at the scene exists,the CSB estimated it from other known events. 17 Although functioning in accordance with the Ghent Volunteer Fire Department guidelines,the captain had no formal incident command training and did not establish command in accordance with NIMS. 17 Little General Store September 2008 Shortly thereafter, two EMTs arrived in an ambulance. The surviving EMT told investigators that he saw the IC at the store's front door when he arrived. According to the Little General store manager,the IC had ordered the business to close." The IC asked the EMTs to follow him behind the building to treat the junior technician for a burn on his forearm. The EMTs examined the junior technician and determined that the burn was frostbite likely from the releasing liquid propane. Following the medical examination,the IC sent the EMTs to the front of the store to ensure that the business had closed, gasoline was not being pumped,and no one was smoking. One EMT walked to the store entrance and found it locked; however,he was able to speak to the Little General employees inside to confirm that the business was closed. The Little General employees had hung a small sign on the door to inform customers that the store was closed due to a gas leak. The EMT positioned himself in the parking lot and proceeded to direct traffic and customers away from the property. Just after 10:50 am, the lead technician returned to the store. He parked in front of the building and walked to the area of the tanks. A firefighter arrived in his personal vehicle to assist with the emergency and checked in with the IC. The firefighter saw the IC and the two technicians working around the leaking tank; he could hear the escaping propane. The IC ordered him to"make sure everybody's out, okay?" However,as the firefighter began walking to the front of the store,the propane ignited and exploded. 18 When ordered to close,the Little General employees turned off the gasoline pumps,locked the doors,and remained in the building. 18 Little General Store September 2008 The explosion killed four near the tanks(the two technicians,the IC, and one EMT). The four workers inside the building and the firefighter survived but sustained serious injuries. The EMT, who was directing traffic and customers, suffered an arm injury. The explosion leveled the building,destroyed a Ghent Volunteer Fire Department ambulance(cover photograph),and damaged many parked vehicles. The force of the blast threw the Ferrellgas tank about 80 feet and the Thompson tank about 50 feet. Figure 5 is an event timeline of the initial emergency response. 10:40 10:51 JT calls 911 LT arrives 10:53 / 0 First report of explosion ss JT ca LT 0:51 Firefighter arrives in personal vehide 10:47 10:56 Incident Commander arrives Beckley,Princeton,and Beaver Fire Departments dispatched 048 EMTs arrive in Ghent ambulence Key: Junior Technician—JT(blue) Lead Technician—LT(green) Figure 5. Timeline of incident response. 19 Little General Store September 2008 3.0 Propane Incident Frequency 3.1 United States Hazardous Materials Incidents 2001 — 2006 The National Fire Incident Reporting System(NFIRS) is the United States Fire Administration's database of fire and emergency incidents. The CSB reviewed the NFIRS database for the years 2001 to 2006 to determine the frequency with which United States fire departments responded to propane incidents. In this six-year period,the NFIRS database includes 36,744 hazardous materials responses in the United States.19 Of these responses, 35.3 percent were responses to releases of gasoline, natural gas,or propane. Incidents involving propane occur nearly once per day. Table 1. U.S. hazardous materials incidents 2001-2006. Total hazardous Natural materials Gasoline Gas Propane incidents 2001 658 468 157 4154 2002 817 627 210 4661 2003 1084 830 263 5904 2004 1149 863 234 6307 2005 1423 1151 301 8301 2006 1406 997 317 7417 Total 6537 4936 1482 36,744 19 As not all states require participation in NFIRS data collection,the total number of hazardous materials responses may not be exhaustive;however,the CSB and the U.S. Fire Administration consider the types of responses representative of the United States as a whole. 20 Little General Store September 2008 3.2 Recent Propane Incidents Since the explosion in Ghent,several similar propane release incidents have occurred in the United States. The CSB researched five incidents similar to the Little General incident(see Appendix C). Three incidents involved only propane releases and two involved releases and flash fires. In the three release-only incidents,both firefighters and propane service technicians responded. A propane service technician secured one of the incident tanks,and firefighters trained in hazardous materials response secured the other two. No injuries occurred in these incidents. The two incidents involving releases and flash fires both occurred at sites where propane service technicians were involved in tank-to-tank transfers of liquid propane. In these cases, fire departments responded, and in both incidents destroyed the structures located nearest the propane tanks. One flash fire injured a person onsite. The other killed one propane service technician and severely injured two others. Firefighters,propane service technicians, or both regularly respond to propane release incidents. The successful mitigation of a release depends on the training and experience of both groups. Additionally,shortly before the Ghent incident, a liquid propane release and explosion occurred at the Falk Corporation facility in Milwaukee, Wisconsin on December 6, 2006. Employees discovered a pool of liquid propane near a propane pipeline. Most employees began evacuating;three remained to attempt to repair the leak. About 10 minutes after the pool of propane had been discovered, it ignited,killing the three employees and injuring over 40 others. OSHA cited Falk and its piping contractor for failing to prepare employees for emergencies involving liquid propane. 21 Little General Store September 2008 4.0 Propane System Fundamentals 4.1 Propane Properties Propane is used extensively as a fuel for cooking and heating in residential, retail, and commercial applications.20 It is a gas at ambient temperature and pressure but is transported and stored as a liquid. Propane-air mixtures can be explosive when the atmospheric concentration of propane is between 2.4 and 9.5 percent by volume. Because propane is odorless and colorless, small quantities of an odorizing chemical(ethyl mercaptan)are added so leaks can be detected by smell. Unlike natural gas,propane is heavier than air. Consequently, propane releases tend to accumulate at ground level or in other low points such as pits and basements. 4.2 System Features The propane system at Little General consisted of a stationary 500-gallon storage tank(Figure 6)and two supply regulators to reduce the pressure of the propane for pizza ovens used in the store. The storage tank had five connections: 1. A fill connection fitted with an internal check valve; 2. A liquid level gage to measure the quantity of propane in the tank; 3. A relief valve(safety device)to prevent over-pressurization of the tank; 4. A service valve to supply gaseous propane to the regulators; and 22 Little General Store September 2008 5. A liquid withdrawal valve fitted to an internal dip tube for removing liquid propane when necessary. Service Liquid Valve Withdrawal Fill Valve Valve \ Relief Valve 1 1 1 Propane l 1 1 Vapor rt. / 1 Liquid Propane Liquid ' Withdrawal 1 I Dip Tube Figure 6. Typical ASME propane tank. The liquid withdrawal valve incorporated several safety features: 1. A threaded valve plug to protect the valve from foreign material and provide a secondary seal if the primary valve were to leak. 2. A telltale in the threaded area on the valve plug. The telltale is exposed before the plug is completely removed. The telltale releases propane if the primary valve leaks allowing a propane service technician to check for valve leaks before completely removing the plug. 3. A special connector that, when screwed on, opens the valve. 20 According to PERC,about 17.5 million U.S. households use propane as a heating or cooking fuel,excluding grills. About 3,500 companies market propane around the country. 23 Little General Store September 2008 4. An excess flow disk in the valve to limit flow should flow exceed a preset limit, such as during a hose rupture. 4.3 Propane Standards 4.3.1 Occupational Safety and Health Administration The OSHA standard Storage and Handling of Liquefied Petroleum Gases21 establishes specific requirements for most workplaces22 storing and handling liquefied petroleum gases(LP gases)23, including propane. The standard's requirements include, but are not limited to, design,operation,technician training,safety devices,and tank placement. A 500-gallon tank, like the one at Little General, must be located at least 10 feet from buildings. 4.3.2 NFPA Propane Standards Two NFPA standards address propane: the National Fuel Gas Code(NFPA 54),which applies to fixed gas-consuming(including propane)equipment attached to piping, and the Liquefied Petroleum Gas Code (NFPA 58),which applies to the storage, handling,transportation, and use of LP gas. NFPA 58 Chapter 6 addresses installing LP gas systems, including requirements for tank locations. NFPA 58 also requires a 500-gallon tank to be at least 10 feet from commercial and residential buildings. 21 29 CFR 1910.110. 22 Little General is covered by OSHA's occupational safety and health standards. 23 Liquefied petroleum gas is the general term for mixtures of hydrocarbon gases liquefied by pressure and used for cooking,heating,and vehicle fuel. Liquefied petroleum gas can be propane,butane,propylene,butylene or any mixture of these compounds. 24 Little General Store September 2008 4.4 Propane Emergency Guidance 4.4.1 Guidance for Consumers Propane companies(including Ferrellgas and Thompson),NPGA, and PERC distribute literature and publish information on their websites guiding consumers on actions to take during propane emergencies such as leaks and releases. If consumers detect a propane leak, this guidance recommends that they: • Extinguish smoking materials and discontinue the use of lights,appliances,phones,or any electrical or spark producing device. • Evacuate the area or building immediately. • If possible,turn off the gas supply at the tank or cylinder. • Go to a neighbor's house and call the propane company or 911. • Stay out of the area or building where the leak was detected. 4.4.2 Guidance for Emergency Responders Propane Emergencies, published for the NPGA and PERC, is the primary text for training emergency responders to handle propane emergencies. The textbook outlines a process wherein the IC should perform a series of actions prior to attempting remediation of the propane emergency. The first step the textbook specifies is site control; it states that the IC must keep all responders and members of the public clear of the hazard until the scene and the hazard are fully understood. The US DOT Emergency Response Guidebook recommends an immediate evacuation to at least 330 feet in all directions and 1/2-mile downwind for large spills. Responders are cautioned to keep all members of 25 Little General Store September 2008 the public away from the area surrounding the point of the release. In addition, the Guidebook states that propane gas is heavier than air and may settle in low or confined areas. 26 Little General Store September 2008 5.0 Incident and Emergency Response Analysis 5. 1 Liquid Withdrawal Valve Liquid withdrawal valves are rarely used. Technicians only open them when tanks must be completely emptied of liquid. The liquid withdrawal valves on most propane tanks may never be used. At Little General, the day of the incident was either the first or the second time that the plug had been removed from the liquid withdrawal valve in the tank's 19 years of propane service. When the junior technician removed the plug from the liquid withdrawal valve, liquid propane released uncontrollably. The plug, though, has a telltale drilled through the threaded portion (Figure 7) which should have released a small stream of propane once the plug was partially backed out. This should have alerted the technician that the valve was leaking. rlegafMkiNis' .Zym, /VKaaj Figure 7. Incident valve plug (Telltale circled). 27 Little General Store September 2008 The CSB determined that the junior technician likely was unaware of the existence and function of the telltale due to inexperience and lack of training and removed the plug completely. Although the CSB determined that it is highly unlikely the telltale hole was obstructed at the time of the incident, CETP training could have made the junior technician aware of and prepared for the possibility of an obstruction of the telltale. The CETP section on liquid withdrawal valves states: In some cases, a damaged seat may allow an excessive amount of liquid to be discharged when the closing cap [plug]24 is loosened. A bleed hole [telltale] in the closing cap has been provided to vent the liquid before the cap is completely unscrewed. If a significant amount of liquid continues to be blown from under the closing cap for more than 30 seconds, it can be assumed that the internal seat will not prevent a dangerous amount of gas from escaping. IF IN DOUBT, DO NOT REMOVE THE CLOSING CAP. [CETP 2.2.13] In addition to the information on the valve above, the CETP procedure for transferring liquid propane from a tank to a truck states:25 While removing the plug, if an excessive volume of propane leaks from the valve,reinstall the plug and follow manufacturer's instructions. [CETP 2.2.13] The CSB initially tested and examined the tank and valve in its"as-found"condition. The CSB determined that the liquid withdrawal valve leaked when the tank was pressurized.26 Following this examination and test,the CSB removed the valve from the tank,performed additional examinations and 24 Plug(external threads)closures are no longer used with liquid withdrawal valves;therefore CETP refers only to cap(internal threads)closures. 25 CETP contains step-by-step procedures for liquid propane transfer from a stationary tank to a tank truck. Liquid propane transfer from a stationary tank to a second stationary tank is not described in CETP. 26 Nitrogen was used to pressurize the tank since it is inert and allowed this test to be conducted safely. 28 Little General Store September 2008 tests, and partially disassembled the valve. The CSB found the valve jammed, likely because of a manufacturing defect,27 and the valve seal cracked (Figure 8). With the valve jammed in an open position, only the plug stopped the liquid propane from escaping. When the junior technician removed the plug, propane began uncontrollably releasing. Cracks in the seal material likely prevented the excess flow feature from limiting the release. I • r rt, S �; . • ` •• • • a � t +- I • i ' • • Figure 8. Crack in valve seal. 27 A hole bored through the center of the lower guide through which the valve stem moves was determined to be too small for the valve stem to move freely. 29 Little General Store September 2008 5.2 Propane Tank Placement In 1994, Southern Sun installed the 500-gallon propane tank directly against the Little General store's exterior back wall. The tank remained in this position and in operation until the day of the incident. The position of the tank was contrary to both the West Virginia Fire Code and the OSHA LP gas standard. Figure 9 shows a 2003 photograph of the building with the propane tank visible behind a wooden fence. t. If:" ;,-a 1sA' -x �as ' - 11111110111 I 1 ghat' S. le I - agar i Is -Illai IC ell - - �y Photo courtesy of Little General Store, Inc. Figure 9. Pre-incident photograph of the Ferrellgas tank. Multiple witnesses told the CSB that Southern Sun placed the tank against the back wall. Paint patterns on the tank corroborate this: the outward facing side of the tank was painted with the Ferrellgas color and logo, while the side of the tank facing the building was painted with the Southern Sun name and logo (Figure 10). This suggests that Ferrellgas painted only the side of the tank that was accessible. 30 Little General Store September 2008 :k1:11:..s. • 1."' 4 v .rte•, ��. • • _ t L r. to , .� f. • Figure 10. Incident tank side facing building. During the release, witnesses described seeing billowing white clouds striking the building and roof overhang and cascading toward the ground, which is consistent with the known behavior of propane vapor following a liquid release. The peaked roof of the store overhung the exterior walls. The overhang was open to allow ventilation in the store's attic space; restroom exhaust ducts terminated inside the overhang directly above the incident tank. The open overhang and restroom exhaust ducts provided a direct pathway for propane to enter the building. The CSB found that if the tank were placed at least 10 feet from the store, propane likely would not have entered the store in large quantities. 5.2. 1 Southern Sun Acquisition Ferrellgas' acquisition of Southern Sun included a pre-acquisition review of Southern Sun's business and operations, which included inspections of propane systems at select Southern Sun customer locations. In addition, Ferrellgas was allowed to identify and request correction of any deficiencies discovered in the year following the acquisition. According to Southern Sun, only two propane tanks were returned, both 31 Little General Store September 2008 because of illegible or missing tank nameplates. Ferrellgas first filled the tank at the Little General soon after the acquisition, and did not identify the tank placement as deficient.2s 5.2.2 Ferrellgas Inspection and Quality Review Program 5.2.2.1 Ferrellgas Inspections The Ferrellgas inspection program for propane systems at customer locations consists of two separate activities: the driver's pre-fill inspection,where delivery personnel visually inspect the system and the Ferrellgas Installation Review(FIR),where an experienced service technician visually inspects the system and records the findings. 1) Drivers' Pre-Fill Inspection Drivers perform pre-fill inspections prior to each propane delivery at a customer location. This visual inspection includes the tank,visible piping,regulators, and the area around the tank. Ferrellgas trains drivers to inspect the installation for potential deficiencies such as tank damage or corrosion, accumulations of combustible materials near the tank, fitness of piping and regulators, tank placement and new structures near the tank, and tank labeling. The driver does not record the results of the pre-fill inspection,but does have the authority to remove the system from service upon finding unsafe conditions. The driver must also report unsafe conditions to management so that a service technician can fix any noted problems. Ferrellgas training materials for delivery drivers discuss tank placement and clearly state that 500-gallon propane tanks must be at least 10 feet from buildings. 28 The week prior to the incident,Appalachian Heating had also replaced another Ferrellgas tank that was placed less than 10 feet from a different Little General Store location. 32 Little General Store September 2008 Ferrellgas filled the tank at Little General Store about 14 times per year; in the 10 years that Ferrellgas owned the tank, drivers would have performed more than 100 pre-fill inspections. The CSB interviewed several drivers who filled the Little General tank and performed the required inspections. All drivers stated that they believed the tank was permitted to be directly against the building's exterior back wall either because it was"grandfathered,"29 the installer had received a variance from local authorities,30 or there was no other place to install the tank. 2) Ferrellgas Installation Review The Ferrellgas Installation Review(FIR)71 is a visual inspection of the installation at a customer's site. The FIR includes the same topics as the driver's pre-fill inspection; however,the inspector records the results either on a form or handheld computer. The service center receives the results of the FIR,records deficiencies, and dispatches service technicians to repair noted problems. Ferrellgas performed two FIRs on the Little General Store installation in 2000, four years after acquiring the tank(Appendix A). These inspections were two months apart; neither inspector noted the placement of the tank on the form.32 Both inspectors told CSB that they could remember neither the inspections nor the reasons for not reporting the tank's placement in the FIR. 29 They believed that the tank installation predated the 10-foot clearance requirement,and was permitted to remain next to the building under some previous set of rules. 30 Local authorities issue formal waivers from code requirements such as the tank placement distances,which are known as variances. Ferrellgas training materials reference the possibility of obtaining a variance from local authorities;however,a variance was not issued for the placement of the tank at Little General. 31 Ferrellgas called this inspection program the FIR during the time it owned the incident tank. The review has been renamed and is now called the Product Installation Review. The methodology for inspection has not changed. 32 Checking the location of an installed tank is step one in the FIR procedures,which states that tanks that do not meet the 10-foot placement requirement must have a written variance from local authorities. 33 Little General Store September 2008 5.2.2.2 Ferrellgas Quality Review Program Ferrellgas's Quality Review program"comprises two annual internal audits;each reviews safety and quality at a Ferrellgas service center location. Each service center's general manager(SCGM)conducts one audit(the SCGM audit), and a regional technical analyst conducts the other(the regional technical analyst audit). 1. Service Center General Manager's Audit Since 2005,Ferrellgas has required its SCGM to perform quarterly audits of his service center. Each SCGM uses a standard checklist-based procedure to audit specific segments of the business according to the following schedule: • First Quarter: Administration, including delivery, installation,and training documentation,operating procedures,and inspection results; • Second Quarter: Plant operations, including piping,tanks,system and container integrity, and operator proficiency; • Third Quarter: Delivery operations, including delivery trucks' integrity and roadworthiness, and driver proficiency; and • Fourth Quarter: Customer installations, including inspection of 10 old and 10 new systems.34 33 The Quality Review program is independent of the FIR and the driver's pre-fill inspection. Neither audit is scheduled to coincide with a system installation or propane delivery. 34 New installations might be placed by Ferrellgas during the year or be acquired by buying other preexisting propane systems. 34 Little General Store September 2008 The CSB requested all SCGM audits from the Princeton and Beckley, West Virginia,service centers for the 10 years preceding the incident. Ferrellgas provided SCGM audits from 2005 and 2006 but provided no documentation of any customer installation audits. 2. Regional Technical Analyst Audit At least once annually, regional technical analysts(known as operations managers prior to 2005)conduct compliance and safety audits at Ferrellgas service centers in their respective regions. The audit is similar to the SCGM quarterly audit in that the technical analyst examines delivery operations,administration, plant operations, and customer installations, using a checklist to guide the audit and record the results. The only apparent difference is that the technical analyst performs all four segments of the audit within one to two days and the SCGM examines one segment per quarter. 5.2.3 Ferrellgas Inspection and Quality Review Program Analysis At least six Ferrellgas delivery drivers and service technicians were in a position to identify and report the incorrect placement of the tank behind Little General; none did. Although Ferrellgas training materials discuss correct tank placement and list tank placement as an inspection criterion for which drivers and technicians may remove tanks from service, the employees who filled and inspected the tank believed that its location was approved.35 The SCGM customer installation audits for the Beckley and Princeton offices were likely not conducted.36 Had managers performed these audits, it is still possible that because of the sampling methods used they 35 All Ferrellgas drivers and technicians reported to the CSB that they had received training in accordance with Ferrellgas procedures. 36 Ferrellgas was unable to provide any documentation of customer installation audits for the ten years preceding the incident. 35 Little General Store September 2008 would not have detected the improper installation at Little General. Ferrellgas' instructions on conducting audits merely recommend SCGMs inspect customer installations that were filled on the day prior to the review or inspect those that the manager is driving past. These methods of sampling provide no way to systematically review all installations over time. SCGMs' and regional technical analysts' audits focus primarily on identifying and correcting deficiencies at facilities and customer locations. Only those installations that are spot-checked during the quality review are corrected; therefore broader systemic problems may remain undetected. In contrast, generally recognized and accepted practices for auditing safety management systems focus on assessing and verifying system effectiveness.J7 These practices include using statistical sampling, trend analysis, management system review,and corrective action to detect systemic problems and ensure ongoing hazard control throughout the organization.38 5.3 Propane Service Technician Training and Response 5.3.1 Propane Service Technician Training 5.3.1.1 Federal and State Training Requirements The United States Department of Transportation(DOT)and OSHA regulations have limited propane service technician training requirements. DOT requires training only for propane personnel who engage in transportation activities. OSHA requires training for propane service technicians but does not elaborate on this requirement(Section 6.1). 37 Standard safety texts describe audits as systematic,independent reviews that determine conformance to company and industry standards whereas inspections are physical inspection of installations and facilities. 38 CCPS, 1993;Petersen,D., 1996;Weinstein,M.B., 1997 36 Little General Store September 2008 Some form of state-mandated training and/or testing requirement for propane service technicians exists in 14 states, and 10 of those have specific training requirements; however,the depth of training required varies broadly. No states require emergency response training for propane service technicians. Three states require licensing for propane service technicians. States use licensing to establish and enforce minimum competency standards for technicians;collect funds for inspection,compliance, and training programs; and communicate technician qualifications to consumers. In the states that license propane service technicians,CETP is an accepted training program. Additionally, at least 10 states have licensing programs applicable to propane and natural gas appliance installers. Recurrent licensing requirements, based on state-established standards of training, testing, and/or experience,aim to ensure that only qualified personnel work on indoor propane and natural gas systems. West Virginia does not require propane service technicians to be trained, certified, or licensed. Appendix D contains a table of the state requirements.39 5.3.1.2 NFPA 58 Training Recommendations NFPA 58 recommends training for propane industry employees who perform activities within its scope, which includes those who transport and transfer LP gas. The standard states that these employees"shall be trained in proper handling procedures. Refresher training must occur at least every 3 years. The training shall be documented."40 An appendix note states that refresher training may be less intensive than original training. However, NFPA 58 does not elaborate on what constitutes initial training. It includes no guidance suggesting a scope,timeframe,or testing component for facilitating an enforceable training standard for states that have adopted NFPA 58, including West Virginia. 39 Information on state training requirements was provided to the CSB by PERC. 40 NFPA 58—2008 Section 4.4"Qualifications of Personnel." 37 Little General Store September 2008 5.3.1.3 Propane Industry Training Program PERC and the NPGA developed its comprehensive training curriculum for propane industry employees, CETP, in 1988. Although CETP is voluntary in most states, many employers in the propane industry use it to train and certify employees. PERC offers the task-based modular curriculum both in instructor-led settings and as a computerized self-teaching program, and sells course materials to employers for in- house training and preparation for CETP certification tests. CETP consists of eight modules. Applicable training modules include • Propane"basics," including properties of propane, industry standards and organizations,bulk plant and delivery vehicle identification,safe work practices,and reacting to interruptions of customer gas service; • Propane delivery, including equipment and operating procedures, loading and unloading, inspecting delivery trucks and installed propane systems,responding to customer calls, and evacuating propane tanks; and • Propane vapor distribution system installation, including transporting tanks and cylinders, installing aboveground and underground tanks, installing regulators and piping,performing leak checks, documenting installations,and communicating safety information to customers. Employers may select topics as appropriate to address job tasks for individual employees, who may then take certification exams in those areas for which they have completed training. For example,customer service representatives often complete the propane basics module,and delivery drivers complete the 38 Little General Store September 2008 propane basics and propane delivery modules. Companies may also augment the curriculum to include company-specific policies and information 41 An important part of the CETP curriculum is its skills testing component. The training program itemizes basic propane procedures; within 12 months of passing the CETP certification exam, certification candidates must demonstrate these procedures and be evaluated. The CETP curriculum includes skills assessment forms; a trainer or other supervisor with sufficient experience must observe a certification candidate perform or simulate procedures correctly, document performance evaluations for each set of procedures, and forward the documentation to PERC before the candidate is certified to work alone. The junior technician at Little General was preparing for a tank-to-tank transfer of liquid propane. Although a CETP module provides step-by-step procedures for liquid transfers to and from bulk delivery trucks, such procedures do not exist for tank-to-tank transfers. While some propane companies may develop their own instructions for this task,the junior technician had no written procedure for his activities on the day of the incident. 5.3.1.4 Propane Service Technician Emergency Response Training A propane incident involving fire department response occurs nearly once per day in the United States (see Table 1). The CSB found that propane service technicians routinely respond to these emergencies. When the lead technician returned to the Little General store in response to the emergency, he was functioning as a specialist responder, with expertise in propane and propane systems. By the time he arrived,a hazardous materials release had been underway for at least 20 minutes. However,his training had not included an emergency response component. 41 PERC offers the Safety and Training Administrative Records System(STARS),a computer-based program for record keeping and training management,which also allows employers to add their own policies to modules. 39 Little General Store September 2008 The CSB found a number of other incidents in which propane service technicians assisted first responders in emergencies involving their companies' equipment and product. First responders consider propane service technicians to be"product and container specialists"who have more experience dealing with propane and its systems than firefighters,police,paramedics, and EMTs.42 Although propane service technicians are not trained to take action to mitigate a hazardous materials emergency without specific training,43 emergency responders often seek their advice and assistance. PERC and the NPGA provide a Propane Emergencies training curriculum for first responders that addresses the role of propane service technicians in the incident command structure(see Section 5.3). However,CETP only briefly addresses emergencies at bulk plants and traffic accidents involving delivery vehicles. No CETP module specifically addresses the potential emergencies service technicians encounter or the basics of hazardous materials incident response. 5.3.2 Thompson Gas/Appalachian Heating Employee Training Thompson Gas Propane Partners, LLC required all propane service technicians to be CETP-trained to the appropriate level for their jobs. The 2005 contract with Appalachian Heating defines responsibilities, including employee training: Appalachian is responsible for ensuring that all employees working with propane are qualified"as defined in NFPA 54 and 58"and CETP-trained for their particular jobs. The specific requirements include completion of CETP 1.0,Basic Principles and Practices,within 30 calendar days of first working for Appalachian/Thompson, and completion of other applicable modules within one year. Additionally,Appalachian Heating must maintain all training records and certifications,provide ongoing training, and update the staff list for Thompson Gas before any new employees begin working. 42 Propane Emergencies,PERC and NPGA,3`d edition,page 44. 43 HAZWOPER Standard,29 CFR 1910.120(q). 40 Little General Store September 2008 Thompson provided CETP training for Appalachian's lead technician in 2006,including the basic principles,delivery,and vapor distribution system installation modules. Experienced Thompson trainers directly supervised his performance of propane service and delivery tasks for nearly a year. This was combined with the CETP classroom training to ensure that he was able to demonstrate proficiency and pass certification examinations prior to working unsupervised. The junior technician began working in the propane business in mid-December, about 45 days prior to the incident. However, Appalachian did not inform Thompson of the new employee. At the time of the incident the junior technician had not trained with CETP and had not received any other formal propane service training. Had Appalachian Heating implemented the training procedures required by the contract, the junior technician would have, via CETP,become familiar with a range of procedures and situations that might occur in the course of working with propane including operation of the liquid withdrawal valve. 5.4 Fire Department Response The IC arrived at the Little General store shortly after the initial dispatch call. In the approximately five minutes from his arrival until the explosion at 10:53 am, the IC took several actions. He: • Assessed the frostbite injury to the junior technician; • Ordered the business to close; • Directed the EMTs to the rear of the building to treat the junior technician's frostbite; • Ordered the EMTs to ensure that the business was closed,that no one was smoking,and that no gasoline was being pumped;and • Ordered the firefighter to ensure that everyone was out of the building. 41 Little General Store September 2008 Guidance for emergency responders in hazardous materials emergencies recommends evacuating and evaluating the situation from a safe distance as the first task. However, the IC's final direction,to ensure that everyone was out of the building, came too late. Within about 30 seconds of the order,the propane ignited and the building exploded. Based on witness statements and the IC's known actions, the CSB determined that the IC allowed the propane service technician to try to correct the propane release while the IC managed the scene. However,the IC was likely unaware of two critical facts: • The junior technician, upon whom the IC was relying to correct the release, was neither trained nor experienced in propane transfer operations and propane emergencies(Section 5.3). • The building was filling with a flammable mixture of propane and air. While the IC was concerned with ignition sources outside such as cigarettes and vehicles, ignition sources inside the building remained uncontrolled during the release. Without knowledge of these facts,the IC was likely unable to fully understand the severity of the emergency at Little General,even though he was fully trained in accordance with the rules of the West Virginia Fire Commission. 5.4.1 Hazardous Materials Incident Training for Firefighters West Virginia requires all firefighters to receive basic training in hazardous materials incident response. This training is required prior to working as a firefighter and therefore is generally conducted only once, 42 Little General Store September 2008 early in a firefighter's career. In contrast, chemical facilities and refineries in the United States that maintain hazardous materials response teams are required to train team members annually 44 The required hazardous materials incident response training teaches firefighters to identify hazardous materials and incidents involving hazardous materials, use DOT's Emergency Response Guidebook,and recognize when additional resources are necessary. The training instructs firefighters to take only defensive actions when encountering a hazardous materials incident; it does not give firefighters the knowledge or skills to enter the area of the release and attempt to stop the release. This action is reserved for organized hazardous materials response teams. The IC at Little General attended a hazardous materials incident response course in 1998. This was a higher-level course than required(see Section 6.3 for requirements),and included topics such as incident risk assessment, selection of personal protective equipment, and control techniques, and a practical exercise. However, this training occurred nine years before the Little General incident, and the CSB found no documentation that the IC had attended refresher training or practical exercises. Unrehearsed knowledge decays over time; hazardous materials incident response skills acquired in training are more difficult to retain without regular refresher training or practice.45 5.4.2 Propane Industry Training for Emergency Responders The Propane Emergencies training program offered by PERC and the NPGA is free to fire departments around the United States. The program trains first responders to recognize the specific hazards of a 44 29 CFR 1910.120 requires industrial hazardous materials incident responders to attend eight hours of refresher training annually. 45 For a full discussion of skill loss,see Arthur Jr,W.,Bennett Jr.,W.,Stanush,P.,&McNelly,T. (1998)."Factors That Influence Skill Decay and Retention:A Quantitative Review and Analysis,"Human Performance,Vol. 11, pp. 57-101. 43 Little General Store September 2008 propane release and treat it as a hazardous materials incident. It emphasizes the importance of evacuating the incident area and evaluating the hazards from a safe distance prior to taking other actions. Additionally,it addresses incident command structure implementation and the advisory role of propane service technicians. None of the Ghent Volunteer Firefighters had participated in this program. 5.5 911 Emergency Call Center Response At many 911 call centers around the United States, operators use quick-reference guide cards to help them evaluate caller emergencies, gather pertinent incident details, and convey life-saving information to callers. Several organizations in the United States produce pre-written guide cards for 911 centers to purchase.46 These guide cards provide easy-to-access information for operators, including questions relevant to the emergency and instructions to be given to the caller prior to emergency services' arrival. Specific sets of guide cards exist for health and injury, fire service, and police response emergencies. Raleigh County 911 uses guide cards for health emergencies and injuries only. At 10:40 am on the day of the incident, the propane service technician called Raleigh County 911 to report the release and summon emergency services. The operator who received the call did not have a guide card or protocol to help evaluate the situation, collect pertinent information, and provide guidance to the caller. 46 Guide cards are available as printed or electronic references and kept at each operator's station. 44 Little General Store September 2008 The propane industry developed a model questionnaire and script to use in situations where customers report propane emergencies such as leaks or releases. The questionnaire prompts personnel answering calls to ask questions such as • Where is the leak? • Do you hear gas escaping? • Is the leak near any building? • Is there an odor of gas in the building? An affirmative answer to these and other questions prompts the gas company operator to read a script that instructs the caller to eliminate ignition sources, evacuate the building to a safe distance, and wait for gas professionals or fire service personnel. Equipping 911 operators with such a prewritten guide can potentially improve safety by initiating important first response actions such as evacuation. 45 Little General Store September 2008 6.0 Regulatory Analysis 6.1 Occupational Safety and Health Administration The OSHA standard regulating propane systems requires that all personnel"performing installation, removal, operation,and maintenance of propane equipment shall be properly trained in such function."47 However,neither the standard, its preamble,nor letters of interpretation define or interpret"properly trained,"nor does it provide for specific training standards,requirements for recurrent training,written testing,or skills testing. OSHA only requires employers to develop training programs they deem appropriate without providing any performance criteria such as those under the industry's program. Additionally,the OSHA standard requires that owners of propane tank(s)be notified prior to work being done on their tank(s)by others.48 Although Appalachian Heating employees removed the liquid withdrawal valve plug from the Ferrellgas tank,Appalachian Heating did not notify Ferrellgas. 6.2 Environmental Protection Agency Firefighters and emergency medical personnel are typically the first responders to hazardous materials spills and releases, like the incident at Little General. However, in 26 states(including West Virginia), state and municipal employees are not covered by the OSHA health and safety regulations that require first responder hazardous materials training.49 In an attempt to close the gap, the U.S. Environmental Protection Agency(EPA)promulgated the Worker Protection standard(Appendix E)50 for municipal and state emergency responders. 4'29 CFR 1910.110(b)(16). 48 29 CFR 1910.1 lo(b)(14)(ii). 49 See CSB Report No.2006-03-1-FL"Bethune Point Wastewater Treatment Plant"for a full discussion. 5°40 CFR 311. 46 Little General Store September 2008 The Worker Protection standard requires states and municipalities to prepare employees for hazardous materials emergencies in accordance with OSHA's Hazardous Waste Operations and Emergency Response standard.51 The standard's requirements apply to career and volunteer fire companies, and public emergency medical response agencies. The United States Fire Administration and PERC52 both cite the Worker Protection standard in their incident response training courses for firefighters. The rules for firefighters and emergency medical personnel in West Virginia, however,do not specifically incorporate the EPA requirements under the Worker Protection standard. 6.3 West Virginia Fire Commission The primary role of the Fire Commission in West Virginia is the promulgation of the state fire code and certification requirements for fire departments. 6.3.1 Requirements for Fire Departments53 The West Virginia Fire Commission certifies fire departments every five years based on • location,size and boundaries of the fire protection district; • number of active and available personnel and their level of training; • quantity and type of equipment; • administrative procedures and policies including chain-of-command; 51 29 CFR 1910.120—Hazardous Waste Operations and Emergency Response generally requires employers to develop emergency response and health and safety plans that address worker training,preparedness,and health monitoring. The regulation applies to both long-term hazardous waste clean-up operations in addition to emergency response for incidents involving any hazardous material(not limited to hazardous wastes). The standard requires initial training and annual refresher training. 52 Propane Emergencies,3rd ed.,p.41. 53 W VC 29-3-2. 47 Little General Store September 2008 • 911 service and mutual aid agreements for the area served; • the department's record of response to emergency calls; and • recordkeeping and NFIRS reporting.s" On April 1, 2005,the Fire Commission published an administrative policy to assist it in its evaluation of fire departments.55 The policy addresses certifying and training active personnel in fire departments, requiring them to attend Firefighter Level I, first aid,cardio-pulmonary resuscitation(CPR),and hazardous materials response training. The Fire Commission's policy specifically requires the following for hazardous materials response: Fire department members and officers shall be trained in NFPA Standard No.472,Professional Competence of Responders to Hazardous Materials Incidents.5b All Fire Department personnel shall be certified at the Awareness level. Fire Department personnel that operate at hazardous materials incidents must minimally meet U.S. Environmental Protection Agency and U.S. Occupational Safety and Health Administration requirements for response at the Operations level. Additional training should be at the discretion of the fire chief based on possible involvement with hazardous materials incidents unless otherwise directed by federal or state statutes, rules and/or regulations. [WVC 29-3-90)] Unlike requirements for industrial hazardous materials incident responders,this Fire Commission requirement does not specifically address recurrent training. All active industrial hazardous materials 54 The criteria are located in WVR 87-6-5. 55 The administrative policy is found at WVC 29-3-9(i). 56 NFPA 472 was renamed the Standard for Competence of Responders to Hazardous Materials/Weapons of Mass Destruction Incidents in the 2008 revision. 48 Little General Store September 2008 responders in the United States are required to undergo an annual refresher course. Yet firefighters,who are likely to respond to many incidents involving gasoline,natural gas,or propane—all hazardous materials—in any given year, are not specifically required by the West Virginia Code to complete an annual refresher course or perform regular response drills. As discussed in Section 5.4,the IC in the Ghent incident had not trained for or practiced hazardous materials emergency response in almost 10 years. 6.3.2 West Virginia Fire Code West Virginia has a comprehensive statewide fire codes' The fire code incorporates,by reference, the majority of the NFPA's standards and guides. Incorporated standards include NFPA 472,which addresses response to hazardous materials incidents. NFPA 472 defines the levels of response to hazardous materials incidents—awareness,operations, technician, incident commander, and specialist employee— and outlines basic expectations for responders at each level. The NFPA's definition of awareness level personnel is consistent with OSHA's definition:55 awareness level personnel are those who,during the course of their normal job functions, could encounter emergencies involving hazardous materials. These persons must be able to recognize hazardous materials emergencies,protect themselves,call for trained assistance, and secure the area.59 Awareness level would apply to propane service technicians like the junior technician at Little General when the release began, since they may encounter propane emergencies during the course of their duties. Operations level personnel respond to already-discovered hazardous materials incidents,taking actions to protect people,the environment, and property from the effects of the release. They are qualified to take 57 West Virginia Rule Title 87 Series I Fire Code. 58 29 CFR 1910.120 59 NFPA 472 Chapter 4 49 Little General Store September 2008 defensive actions to mitigate the damage caused by a hazardous materials incident,but not to actively handle or attempt to contain the hazardous material(s). This type of action might include assessing the scene and planning a response, establishing evacuation perimeters, setting up communications, and initiating the incident command system. The operations level designation applies to anyone arriving at the scene in response to a hazardous materials emergency; in Ghent,the lead technician,the EMTs,and the fire department personnel acted at an operations level by arriving at the Little General in response to the junior technician's phone call. Hazardous materials technicians, in contrast, are those qualified to take defensive and offensive actions in response to an incident. Offensive actions entail entering the incident"hot zone"to attempt to control a release,and require additional training beyond the operations level 60 Additionally, hazardous materials responders may seek the help of specialists: industry employees familiar with and trained in the hazards and systems of a given material, like propane. Specialist employees must also meet specific NFPA 472 competencies to be qualified to perform release control actions. Propane service employees who assist emergency responders physically secure releases must meet at least these competencies. Although the evidence and witness statements indicate that the Appalachian Heating employees and Ghent Volunteer Fire Department personnel were standing in the vapor cloud and attempting stop the release, none were trained to the technician or specialist level. 6°Technician level training corresponds to 29 CFR 1910.120 40-hour HAZWOPER training. 50 Little General Store September 2008 7.0 Findings 1. The propane service technicians, emergency responders, and store employees did not evacuate the area as recommended by nationally accepted guidance for propane emergencies. In fact,emergency responders and the propane service technicians were observed standing in the propane vapor cloud. 2. Propane companies,the National Propane Gas Association,and the U.S. Department of Transportation recommend evacuation to a safe distance as the first action in response to a propane release. 3. The fire department captain, the propane service technicians,and the Little General Store employees were unaware of the dangerous propane accumulation inside the building. 4. A defect in the existing tank's liquid withdrawal valve caused it to malfunction and remain in an open position. 5. About 25 minutes elapsed from the time the release began until the explosion. 6. Both the U.S. Occupational Safety and Health Administration's and the West Virginia Fire Commission's propane standards require a distance of at least 10 feet between 500-gallon propane tanks and buildings such as the Little General Store. However,when the Southern Sun propane company installed the propane tank in 1994 it was placed directly against the Little General Store's exterior back wall. 7. Ferrellgas,which acquired Southern Sun in 1996,allowed the tank to remain against the building's exterior wall for more than 10 years. 8. The placement of the 500-gallon propane tank against the building's exterior wall provided propane a direct pathway into the store's interior during the release. 9. Ferrellgas management's quality review program functions as a basic safety inspection rather than a management systems audit. 51 Little General Store September 2008 10. The junior propane service technician who was servicing to the tank on the day of the incident had no formal training and did not recognize the defect in the withdrawal valve. He was also working alone even though he had been on the job for only one and a half months. 11. Propane service technicians commonly do not receive emergency response training. 12. The propane industry's primary training curriculum(the Certified Employee Training Program) consists of procedures and materials for performing routine (non-emergency)tasks only. 13. The Occupational Safety and Health Administration's and National Fire Protection Association's propane standards require training but do not include curricula, practical exercises, emergency actions,or knowledge evaluation tools. 14. A propane emergency significant enough for fire department response is reported nearly everyday in the United States. Only gasoline and natural gas are involved in more hazardous materials emergencies. 15. 911 operators in the United States lack propane emergency guidance to help them collect important information from callers,offer life-saving advice, and convey relevant information to first responders. 16. Minimal information on the nature of the incident was exchanged between the propane service technician and the 911 operator. Therefore,the only information the 911 operator provided the Ghent Volunteer Fire Department responders was the incident location and the"report of a propane leak." 17. Firefighters in West Virginia are required to attend a minimum of four hours of hazardous materials emergency response training as part of their initial training sequence but refresher training is not required. The responding Ghent Volunteer Fire Department captain last attended a hazardous materials response course in 1998. 18. Propane safety and emergency training is voluntary for fire department personnel in West Virginia. None of the responders from the Ghent Volunteer Fire Department had specific training relating to propane emergencies. 52 Little General Store September 2008 8.0 Causes 1. The Ferrellgas inspection and audit program did not identify the tank location as a hazard. Consequently,the tank remained against the building for more than 10 years. 2. Appalachian Heating did not formally train the junior technician,and on the day of the incident he was working alone. 3. Emergency responders were not trained to recognize the need for immediate evacuation during liquid propane releases. 53 Little General Store September 2008 9.0 Recommendations Governor and Legislature of the State of West Virginia 2007-04-I-WV-RI Require training and qualification of individuals who operate bulk propane plants,dispense and deliver propane,install and service propane systems,and install propane appliances. The training and qualification requirements should be comparable to those of existing propane industry programs such as the Certified Employee Training Program. West Virginia Fire Commission 2007-044-WV-R2 Revise the Fire Commission rules and codes to require annual hazardous materials response refresher training for all firefighters in West Virginia. 2007-04-I-WV-R3 Revise the Fire Commission rules and codes to require that all West Virginia fire departments perform at least one hazardous material response drill annually. West Virginia Office of Emergency Medical Services 2007-04-I-W V-R4 Revise the Office of Emergency Medical Services rules and codes to require annual hazardous materials response refresher training for all emergency medical personnel in West Virginia. 54 Little General Store September 2008 National Fire Protection Association 2007-04-I-WV-RS In the Liquefied Petroleum Gas Code(NFPA 58)"Qualifications for Personnel"section,specify training requirements (including supervised on-the-job training), training curricula,competencies, and testing through written examination and performance evaluation,or reference a nationally recognized curriculum for these requirements. Association of Public-Safety Communications Officials 2007-04-I-WV-R6 Develop a guide card for propane emergencies to assist 911 operators in the collection of pertinent information on propane emergencies. The questionnaire in Section 1.9.1 in the Propane Education and Research Council's Certified Employee Training Program may be used as a model. Propane Education and Research Council 2007-04-I-WV-R7 Revise the Certified Employee Training Program to include • Procedures for transfer of liquid propane from tank to tank,or • The prohibition of the transfer of liquid propane from tank to tank. 2007-04-I-WV-R8 Revise the Certified Employee Training Program to include emergency response guidance for propane service technicians who respond to propane emergencies similar to guidance provided to emergency responders in the Propane Emergencies program. 55 Little General Store September 2008 National Propane Gas Association 2007-04-I-WV-R9 Submit a request to the United States Occupational Safety and Health Administration for a letter of interpretation to determine if the Certified Employee Training Program curriculum meets the training requirements in 29 CFR 1910.110. 2007-04-I-WV-RI0 Work with the West Virginia E911 Council with development of propane emergency guidance by providing the Council with the customer leak questionnaire located in Section 1.9.1 of the Certified Employee Training Program and technical assistance. West Virginia E911 Council 2007-04-I-W V-Rh] Work with the National Propane Gas Association to develop and distribute propane emergency guidance for use by all county and municipal 911 communication centers in West Virginia. 56 Little General Store September 2008 Ferrellgas 2007-04-I-WV-R12 Establish and implement a comprehensive safety management system that includes at a minimum: • An auditing program developed in accordance with generally accepted methodologies to monitor the performance and effectiveness of safety management systems and personnel at all levels, • An inspection program that uses NFPA 58 as a guide to systematically inspect all customer propane systems and identify all deficiencies, • A means of tracking audits and inspections and identified deficiencies, • A means of tracking corrective actions, • A means of collecting and using audit and inspection data for trend analysis and organizational learning, • A means of periodically reporting audit and inspection trends to the Board of Directors and Managing Board, and • A provision for periodic safety management system audits conducted by a third party competent in the requirements of NFPA 58. 57 Little General Store September 2008 By the U.S. Chemical Safety and Hazard Investigation Board John S. Bresland Chair Gary Visscher Member William Wark Member William Wright Member Date of Board Approval 58 Little General Store September 2008 References Center for Chemical Process Safety(CCPS), 1993. Guidelines for Auditing Process Safety Management Systems, American Institute of Chemical Engineers(AIChE). Ferrellgas Partners, L.P., 2006. US SEC Form 10-K—Annual Report Pursuant to Section 13 or 15(d)of the Securities Exchange Act of 1934. Hildebrand,M.S.,and G. G.Noll,2007. Propane Emergencies,3r°ed.,National Propane Gas Association (NPGA)and Propane Education&Research Council(PERC). Lemoff,T. C.,ed., 1998. LP-Gas Code Handbook(5`h edition),National Fire Protection Association (NFPA). National Fire Protection Association(NFPA), 2008a. Liquefied Petroleum Gas Code,NFPA 58. NFPA,2008b. National Fuel Gas Code,NFPA 54. NFPA, 2008c. Standard for Competence of Responders to Hazardous Materials/Weapons of Mass Destruction Incidents,NFPA 472. Occupational Safety and Health Administration(OSHA), 2007. Storage and Handling of Liquefied Petroleum Gases, 29 CFR 1910.110, OSHA. Petersen,D., 1996. Analyzing Safety System Effectiveness, Third Edition,John Wiley& Sons, Inc. Raleigh County Emergency Services Agency, 2006. Raleigh County Emergency Operations Plan(EOP). West Virginia Fire Commission, 2004. State Fire Code,Title 87 Series 1 (87CSR1),West Virginia Legislative Rules. Weinstein,M.B., 1997. Total Quality Safety Management and Auditing, Lewis Publishers. West Virginia Legislature, 2007. Fire Prevention and Control Act,Chapter 29 Article 3 (WVR 29-3), West Virginia Code. 59 Little General Store September 2008 Appendix A Ferrellgas Installation Reviews of the Incident Tank 60 Little General Store September 2008 111113 Ferrellgos A ce.eint number - v..:_;_.,,2 • ati-starrsttr i , i ' n _ s ran, r.— 'P,it_.._?._. _. Antd'ess rf.i7 1t- t:1 6 Cory_ t; ._.�I • 1 Sego ` ZIP' .)1J' f:-- --- Ferreilgas Installation Review -. Component checks: �U irei r meters a 1 •I an! _(l aps.'atnr �U Uttered em edor(to* ITank c) 'f [ SN_ tSny'-1 �:4 ._. _... Mfr-. 1.2_:-._12.-__-‘4...._ P .a. ! Y r Tank SAI Mfr. . 541 i t EsCroparadaa nosed __ 4 J System tad tagged? ..afire; 3 Yes •The Fen llgu tastitadon Review(RR)has been ccvnpleied on my gu system if indicated above. r •I know bow to tiro off gu is cue or energettcy. , •1 have studied prochLe eal can detect sa adoe. •I have received the consumer safety iafcentatam slut marenal t •1 andentued propane is flammable and ran be explo.sve, •I know whale to do when I end!gat. •I have had gas swam defs:icocaet en.ila corrections,of any.:learly orphaned tv me •t have reviewed the safety tafcematioo and reecwnmeodat►nns cei the back of this form. Custom anedlod odocered propuc arid was shown t.huri wia paoceil:ire• i .1,Yes 3 Dedyaed '3 Cussorner root available ..- r P cpane Safety P.an(OPR J t:1) Cat!t at rriidu e a Maded a)Ctrnr nce r _ _._ . _ :]141 at trsr.7rese a M itd to cuswrtrr fCmiloraer at hone, O do -cries Dewy � f Sale important>ta.Vy _-..4_ Cr �Intormalksai on beck [eats OP*ttso %v.t i,, MARKET FILE COPY . — 61 Little General Store September 2008 rij Ferrellgns AcL:�JM fu—tW -: Cvl1Lv-ltic .! P-- Ferrollgas Installation Review } Comp';rr19ri*Cb..sC1'C: `i-tua ttar ides. S IA P.tiJE::r Ake chtcki Tank - �_S.t1 . _ _.- !Xi' -- — u Lank S.11 Mfr. 'Jr. i _ SrAern d rrjar? J ti,re J Ilan •T!a Frrrtllias Inualla5 n p.••,s•3.+..!1R j has t.•e:.;mr4uN'.m my sas sysaro it . ic4gase4 as:'•e. •I Imo*bow t...ram AT 1as m:me u(er-ie.•grne p •I Aare um.3.31 arvVant as1:an Arta-..t.13 c.Sa •I have nrrive.J tf a au r s safery inlxassaadi and maienat •I uair'iwid rtcpaae a llaanlnstte Mi can to ett.41Aet+e •1171Mr uttu:.d's+hen I smell gak •11sa.e had gat rnlm-a 3efic...c.s aa'.'t r::m“6-Ita r.if any.clearly tntitlaasxd W mi. •1 have rerir.e..i Ae mkiv ir4d.i.a.'lnn ant re:.+rtmendan.ni;w Woe N..13.of ih'3 C'u. m r ivrI.e.1 i.S-vua3 paKsant url•as:Is,.n•.ta kiwi pv:c lue' .]Yes :]I i.q'-Iced :J t_.assorrais n:4 atLigie 1T'Ysa.x See y Plan 44-WR-11-11 '-.]l 41 al r*-aYn:r. .J M.le>i M•:trtk'i*v Cl I.ril II mu Jrsa:e '.J Masks!w C.,sk.nter C'S.a .rt at!r:r'tr? :3;4;3 1"•t M.wrsa*1 o.as.tf / rwx.nata n LYi N.* — — ra•eb...rw+weae...�' ``_'--1 Ay. I1.. . MARKET FILE COPY 4 r 62 Little General Store September 2008 Appendix B 911 Call and Initial Fire Department Dispatch 63 Little General Store September 2008 Emergency 911 Call — Report of Release AUTOMATED VOICE: Conversation recorded on January 30th,2007,at 10:40,on Channel 7. DISPATCHER: 9-1-1, where is your emergency? CALLER: Yes,ma'am. I need to --I need a fire department down at the Little General Store in Ghent. I need a--I got a propane leak--I need their help to secure the area. DISPATCHER: A propane leak? CALLER: Yes,ma'am. DISPATCHER: What's the address? Is that the one on Odd Road? CALLER: No,ma'am. It's the one actually on, uh--the one going towards Shady Springs. With the Godfather's Pizza. DISPATCHER: Do you know the address? CALLER: No,I don't,ma'am. Right in front of Flat Top Lake. DISPATCHER: Flat Top Lake. CALLER: Yes,ma'am. DISPATCHER: And this is Little General,right? CALLER: Yes,ma'am. DISPATCHER: And this is a propane leak? What is your name? 64 Little General Store September 2008 CALLER: XXXXXXXXXXXXX;' I work for Appalachian Heating;we've had a dysfunction in the tanks, and I have a leaky tank. DISPATCHER: Okay. All right, I'll get the fire department out there for you. CALLER: Thank you. Bye-bye. DISPATCHER: Thank you. Emergency Dispatch — Initial Dispatch Notification to Ghent Volunteer Fire Department AUTOMATED VOICE: Conversation recorded on January 30th,2007, at 10:43, on Channel 21. (Fire tones.) DISPATCHER: Raleigh Control, Station 110 -- Station 110 --you need to respond to Flat Top Road in Ghent,the Little General,across from Flat Top Lake; report of a propane leak. Repeating, Station 110, need units to respond to Flat Top Road at the Little General,report of a propane leak. WGC808, 10:44. Name removed. 65 Little General Store September 2008 Appendix C Recent Propane Incidents 66 Little General Store September 2008 Recent Propane Incidents CSB identified the following incidents for further research based on their similarity to the Little General incident. The CSB interviewed the propane companies, emergency responders, and local investigators involved in these incidents to collect relevant information. The CSB did not conduct an independent investigation. 1 .0 Propane Release Incidents 1.1 Aberdeen, Washington 1.1.1 Incident Description On October 23,2007,the Southshore Mall in Aberdeen, Washington, was evacuated due to a vapor release from a 1,150-gallon propane tank. The tank was located in a utility yard approximately 25 feet from the mall restaurants for which it supplied heat and fuel. Shortly after 2:00 pm,a mall employee heard a"pop"and,upon going outside to investigate,discovered the leaking tank. The fire department responded, evacuated the mall,and isolated the scene. The fire department called the propane company that owned the tank for incident support. The company sent one service technician to assist the fire department. The responding technician found the release was from the tank's fill valve, which had become stuck partially open. The technician installed a double- check valve on the leaking fill valve to stop the release. The fire department lifted the evacuation order by 2:45 pm. 1.1.2 Incident Responders The propane company involved in this incident reported having a preexisting working relationship with the fire department. All the propane company's employees train on job procedures with CETP and 67 Little General Store September 2008 practice emergency response scenarios. The service technician who was sent to assist the fire department had both CETP training on all propane service and delivery procedures and on-the-job experience as a service technician and a delivery driver. In emergency response cases like this one, the fire department is in charge of the scene, with the gas company employees on the scene to assist and advise the fire department as necessary. Occasionally, propane service technicians responding at the request of a fire department take offensive steps to stop a release—in this case,by installing a valve. The fire department's decision to allow the propane service technician to repair the tank was different from the Ghent incident in several important ways: • The fire department had evacuated and secured the scene prior to the technician's entry. • The vapor release from the leaking fill valve was much less severe than the liquid propane release in Ghent,requiring only a small repair for the tank to remain in service safely. • The technician was CETP-certified and experienced,had drilled on emergency response scenarios, and had previously worked with the fire department on propane incidents. When emergency responders and service technicians have clearly established and rehearsed roles in an incident command structure, both groups are better equipped to implement their training. 1.2 Lynchburg, Virginia 1.2.1 Incident Description At about 1:00 pm on November 26, 2007,a traffic accident caused a vehicle to crash into a 1,000-gallon propane tank used for filling cylinders, located outside of a True Value Hardware store in Lynchburg, Virginia. When the vehicle struck the tank,the inch-and-a-half liquid line connecting a pump and the tank was severed. The tank settled on top of the severed pipe, which in turn prevented the excess-flow valve from seating,resulting in a liquid propane release. Hardware store employees called 911 and the 68 Little General Store September 2008 propane company that owned the tank. Although the 911 operator dispatched the hazardous materials response team to the incident as a gas leak,a citizen driving past called the team to clarify that it was a propane release. The team arrived and secured the area, evacuating shoppers from the rear of the hardware store on foot. Since the valve could not be repaired, the response team used water spray to disperse the vapor cloud formed by the liquid release,while keeping the area evacuated. Once most of the propane in the tank had been released,the response team approached the tank and used a strap to completely seal it. They then loaded the sealed tank onto a truck for removal from the area. The release lasted two hours. Propane service technicians from the company that owned the tank also responded. They arrived after the hazardous materials response team, and attempted to approach the tank. Response team members removed the technicians to the incident command post, outside of the release area. 1.2.2 Incident Responders The responding hazardous materials team is an all-career unit,with all members trained to technician level(40-hour)training, which qualifies them to take offensive action in response to releases. According to responders,propane incidents occur frequently in the area; although most involve residential propane cylinders,the hazmat team has responded to several major incidents. As a result of the prevalence of propane in the area, its hazards are a focus in training sessions. With this training,responders were able to quickly assess the uncontrolled release and evacuate the area. All propane service technicians at the company that owned the tank,a small locally owned business, receive CETP training. Additionally,the company has trained with the fire department in CETP procedures to help emergency responders understand propane systems. However,the CETP program has no emergency response component,and propane service technicians do not train with responders the incident command system or other aspects of hazmat response. As in Ghent,propane service technicians 69 Little General Store September 2008 attempted to take an active role in release mitigation without hazardous materials or emergency response training. However,unlike Ghent, fire department responders in this incident were trained and experienced in the hazards of propane releases, and evacuated everyone,including technicians, from the area. 1.3 Bristow, Virginia 1.3.1 Incident Description On May 19,2008,the Linton Hall School in Bristow,Virginia,was evacuated due to a vapor release from a 500-gallon propane tank. The tank was located 15 to 20 feet from the school, near the cafeteria kitchen. At about 11:20 am,a trash truck backed into a chain connecting the tank to a light pole, overturning the tank and shearing off its service valve,causing a propane vapor release. School administrators called 911 and the propane company that owned the tank, and evacuated the 205 students and 30 faculty members according to routine fire drill procedures. The 911 operator who received the call dispatched the county fire department to the incident as an outside gas leak. The first responding fire engine company arrived on scene,assessed the situation,and revised the call to an inside gas leak due to the tank's proximity to the school kitchen and water heater, dispatching the hazardous materials response team.2 When the team arrived,it sprayed water in a fog pattern to push released vapor down and away from the school,then used a wooden dowel and a towel to plug the leak. Propane service technicians from the company that owns the tank arrived after the team had secured the release and moved the tank to a large open parking lot away from the school to repair the 'A"No Parking"sign hung from the chain. 2 The dispatching system in this county requires the hazardous materials unit to respond to all interior gas leaks. 70 Little General Store September 2008 valve. No one was injured. Students remained at a church across the street until parents arrived to take them home. 1.3.2 Incident Responders The hazardous materials team involved in this incident has responded to several propane incidents in the last year, all of which have been vapor releases. They receive technical information from propane service technicians,but take release mitigation actions themselves. To protect propane service technicians from entering the release area,the team uses methods including • taking digital photographs of tank damage so that technicians can see and assess the damage on a remote laptop computer, • bringing similar tanks or other equipment to the scene so that technicians can point out features the team will find on the incident tank,and • escorting technicians to the edge of the secured release area to point out potential leak sources for team members. Additionally,the hazardous materials response team trains local 911 operators to use follow-up questions to elicit needed information from callers reporting hazardous materials incidents. In this incident, as in Ghent,the 911 operator conveyed little information to the fire department. However, unlike Ghent responders,the first fire engine company to arrive immediately recognized the danger posed by the release's proximity to a building and called for hazardous materials backup. The propane service technicians responding to this incident were branch employees of a national propane company that uses CETP. In the event of a propane emergency, whichever technicians are working nearest the incident stop work immediately and respond. Since these responders are all trained with CETP,they are familiar with what types of incidents they can mitigate using normal propane procedures. 71 Little General Store September 2008 In this case,propane service technicians attempted to repair the tank only after the fire department had secured it and removed it from nearby buildings. 2.0 Propane Release and Fire Incidents 2.1 Sallis, Mississippi 2.1.1 Incident Description On May 13, 2007,a propane explosion occurred at the Longhorn's Steak House in Sallis, Mississippi, while the restaurant was closed and two propane service technicians were transferring propane from an old 500-gallon tank into a new 500-gallon tank behind the building. The transfer procedure had been completed and the new tank was leak-tested and placed in service. The technicians next planned to remove the old tank(which still contained some propane)from the premises,but were unable to load it onto the service truck. They left and returned later in the day with a trailer. As the technicians were loading the old tank onto the trailer, it slid to one side, severing a valve at the bottom of the tank. The technicians heard a loud noise and saw liquid propane releasing from the bottom of the tank and forming a vapor cloud along the ground. They immediately ran toward the front of the building;the propane reached an unknown ignition source and a flash fire occurred seconds later. Another person who was near the front door of the restaurant at the time was badly burned in the flash fire. The building and a pickup truck parked in front were destroyed. Local volunteer fire departments responded,and the Mississippi State Fire Marshal's office investigated. 2.1.2 Incident Responders The propane service technicians were from a local propane company. Although they had already completed a tank-to-tank transfer without incident,they immediately realized the danger of a liquid propane release from the damaged tank. Since the propane reached an ignition source only seconds after 72 Little General Store September 2008 the release began,the technicians were unable to evacuate the person in front of the restaurant before the flash fire. Both reported to investigators that they had attempted to do so. Local firefighters responded and reported the incident as a structure fire. The county sheriff's department informed the State Fire Marshal's Office that propane was involved,and LP Gas Division investigators completed the state's report. 2.2 Danville, Alabama 2.2.1 Incident Description On May 20,2008,three propane service technicians were attempting to perform a tank-to-tank transfer of liquid propane at a farm in Danville,Alabama, when a propane vapor release caused a flash fire. A 1,000-gallon propane tank at a chicken house was reported by property owners to be leaking around the pressure relief valve. Technicians were to replace the half-full tank with a new tank and transfer the remaining propane. The technicians removed the leaking tank from its installed location and placed it to the side,then set the new tank in its place. Employees next used the service truck boom to suspend the leaking tank upside down and at an angle,near the new tank. They planned to use the filler valve to evacuate the old tank, hooking it to a hose with a filler valve adaptor. However, damage to the filler valve caused it to stick in an open position and release propane vapor. The vapor reached the service truck, idling near the transfer location, and ignited setting fire to the chicken house. The town's volunteer fire department was dispatched to a structure fire. When firefighters arrived,they discovered that the fire was due to a propane release. The firefighters then moved the three injured technicians away from the fire, used water to cool the propane tank, and approached the tank in full protective equipment to attempt to close the valve. They discovered that the valve had been sheared off entirely and withdrew,continuing to contain the fire to prevent it from reaching other propane tanks 73 Little General Store September 2008 located 25 to 30 feet away. The firefighters called for the nearest hazardous materials response team to assist them in using thermal imaging to determine how much propane remained in the tanks. The incident tank was empty; no other tanks released. The chicken house was destroyed. All three propane service technicians were severely burned; one died in hospital. 2.2.2 Incident Responders The volunteer firefighters in Danville are all trained using the Propane Emergencies curriculum, which is offered through the state fire college as a two-day program. The fire chief requires that they complete the program twice before responding to propane incidents. This training includes practice on controlled propane releases and fires, and allows the fire department to mitigate propane emergencies without relying on propane companies. If firefighters cannot contain a release, they may let propane service technicians work on the tank,but only if no fire is involved and the area has been secured. 74 Little General Store September 2008 Appendix D Table of State Training, Testing, and Licensing Requirements for Propane Service Technicians 75 1UODUOA X x x CO C0 O 1-- O N N Mai E x x x a) a a) w Ewoyup1 * X x ,Casia f MOM x x x EJlswga(\j x x x x ❑n0SS1W +- x x x x ue8tgotj x x x puel,CIEy, x x x auteysl x x x x EMOI i— x x x x epuuojj x x x x a .D opemlOO m x x P. o o 3 Co. o Ewe9ElV v 2 c x c m C y N 5 O c y /n sesuegq.ry 'c Te * > m x x t g T 0 C 2 w E) O m N 0 O tt a a) ri 3 :e ea c y p, H o 43 O U Zc a N U J OG �' u 2 V 0 1l * } o. V N N © ba 4 N F O. r .a .' .� F Loca 7 C w° o a"' a a b d a w"' Little General Store September 2008 Appendix E United States EPA - 40 CFR 311 77 Little General Store September 2008 311.1 Scope and application. The substantive provisions found at 29 CFR 1910.120 on and after March 6, 1990,and before March 6, 1990,found at 54 FR 9317 (March 6, 1989), apply to State and local government employees engaged in hazardous waste operations,as defined in 29 CFR 1910.120(a), in States that do not have a State plan approved under section 18 of the Occupational Safety and Health Act of 1970. 311.2 Definition of employee. Employee in Sec. 311.1 is defined as a compensated or noncompensated worker who is controlled directly by a State or local government,as contrasted to an independent contractor. 78 U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD Urgent Recommendations Summary of Board Actions: On June 9, 2009,four workers were killed and 67 others were injured in a natural gas explosion at the ConAgra Foods Slim JimTM meat processing facility in Garner, North Carolina. Less than eight months later, on February 7, 2010, six workers were killed and at least 50 others were injured in a natural gas explosion at the Kleen Energy power plant under construction in Middletown, Connecticut. Both incidents had the potential to cause even more severe damage and loss of life. The U.S. Chemical Safety Board investigated both incidents and reviewed the facts surrounding other serious fuel gas incidents in the United States in recent years. Both the explosions at ConAgra Foods and Kleen Energy resulted from planned work activities that led to large releases of flammable natural gas in the presence of workers and ignition sources. The CSB determined that no specific federal workplace safety standards prohibit such intentional releases of natural gas into workplaces. The CSB also determined that feasible alternatives exist to the unsafe practices that led to the explosions at Kleen Energy and ConAgra Foods, and that many companies(though not all)use safer methods for handling or venting natural gas. The Board issues the following urgent safety recommendations to the U.S. Occupational Safety and Health Administration,the National Fire Protection Association, and other parties and votes to conclude its investigations of the ConAgra Foods and Kleen Energy incidents. Whereas: Background and Findings 1. On Sunday, February 7, 2010, Kleen Energy, a combined-cycle' natural gas- fueled power plant under construction in Middletown, Connecticut, experienced a catastrophic natural gas explosion that killed six and injured at least 50.2 2. The incident occurred during the planned cleaning of fuel gas piping,part of the commissioning and startup phase of the Kleen Energy project. At the time of the incident, workers were conducting a"gas blow,"whereby natural gas is forced through the piping at a high pressure and volume to remove debris. The natural In a combined-cycle plant,power is generated by two different processes: in the first,a gas turbine (similar to a jet engine)drives an electric generator to produce electricity;the second uses the turbine exhaust heat to generate steam.The steam powers a turbine to drive a second electric generator. 2 The general contractor provided an evidentiary record indicating that 50 individuals were injured. Due to conflicting company reports,a more accurate number cannot be determined. gas and debris are subsequently released directly to the atmosphere. At the Kleen Energy construction site, workers used natural gas at a pressure of approximately 650 pounds per square inch gauge (prig). 3. A total oI' 15 natural gas blows were completed intermittently over approximately 4 hour through a number of open-ended pipes located less than 20 feet off the ground. These vents were adjacent to the south wall of the main power generation building at the site. 4. On the day of the incident, the pipe cleaning crew did not have a safety meeting that specifically discussed the hazards of natural gas blows, nor did they receive and review the natural gas blow procedure. 5. At the time of the explosion, natural gas was being blown from an open-ended pipe between two large structures, known as heat recovery steam generators (HRSGs), in an area immediately south of the power generation building. This location, while outdoors, was congested by the sun'ounding power generation equipment (Figure 1 ). The vent pipe itself was installed in a relatively horizontal orientation. Both the congested area and the orientation of the vent pipe likely adversely affected the dispersion of the natural gas. j . t • 1. 1 I ` 1 \ s: If( I ) a . MI - ' 1 j' i , _- -- r is r.-.'. , - � ni - 1 ' — a II S S '�t, ‘ a .2 - : J ..• � ' . ' ` •-• s I A I `� et ,� - -ti< Figure 1. The general location of open-ended pipe where natural gas was vented to the outdoors at time of incident (yellow oval). The actual vent piping is obscured by the structure and scaffolding. 6. Efforts were made to eliminate or control potential ignition sources outside of the power generation building. However, ignition sources remained outside and inside. The gas blows themselves could have been self-igniting due to expelled debris creating a spark or through static accumulation from the flow of the gas. Many ignition sources also existed inside the building: electrical power to the building was on, welders were actively working, and diesel-fueled heaters were running. 2 7. Initial calculations by the CSB investigators revealed that approximately 480,000 standard cubic feet of natural gas were released outdoors near the building in the final 10 minutes before the blast. Just over 2 million standard cubic feet of natural gas were released in total over the course of the morning.; 8. At approximately 11:15 am.,the released natural gas found an ignition source and exploded. 9. Approximately 150 workers were at the construction site on Sunday, February 7, the day of the explosion. Non-essential personnel were restricted from the area immediately south of the main power generation building during the gas blows. However, more than 50 people were working inside the power generation building at the time of the explosion; only about 15 of the 50 were actually involved in the natural gas blow activities. 10. While some workers were informed that natural gas blows would be occurring on February 7, others did not learn about the planned natural gas blows until they reported to work that morning. Some contractors were instructed to continue working inside the power generation building during the natural gas blow activities, while other groups were directed to leave while the work was being completed. A few individuals made the personal decision to vacate the building because they were alarmed by the smell of the natural gas odorant. 11. The six individuals fatally injured were all within the power generation building at the time of the explosion;five were involved with the natural gas blow activities and one was not. Similar Natural Gas Blow Incidents 12. A similar natural gas blow incident occurred on January 26, 2003, at Calpine's Wolfskill Energy Center natural gas power plant in Fairfield, California, during its pre-commissioning phase of construction(Figure 2). High-pressure natural gas at approximately 630 psig was vented through four-inch diameter piping directly to atmosphere to flush out debris. 'Two million standard cubic feet of natural gas is more than two billion BTUs worth of gas—enough to fuel a typical American home every day for more than 25 years,assuming typical consumption of 77,900 standard cubic feet per year for a household.(Analogy provided by http://www.aga.org/Kc/aboutnaturaleas/additional/HowtoMeasureNaturalGas.htm accessed June 23, 2010.) 3 _ - 'L '` r 1 - 'l*:- 1 . 1 . ,I, • :y I-_; - -•- ft- ' ,t C • in Figure 2. The Calpine Wolfskill Energy Center gas blow incident 13. The natural gas blow was performed in a congested area; the open-ended pipe was located 10.5 feet off of the ground and situated approximately 10 feet from the gas turbine building. The pipe outlet was located near an overhang of the building that provided between 2,000 and 9,000 cubic feet of confined area in which the dispersed gas could accumulate to an explosive level. While the close proximity of these structures presented potential ignition sources, as their metal surfaces could have caused sparking from expelled debris,4 Calpine determined that the explosion was most likely ignited by static electricity generated from the natural gas flowing at a high velocity through ungrounded piping. 14. Seven people were present, directing or observing the gas blows on January 26, 2003, including a representative from both the turbine manufacturer and the local fire department. They were standing in different locations, from 80 to 140 feet from the venting location, when the explosion occurred. The explosion was powerful enough to shatter windows a quarter of a mile away and was heard up to 10 miles from the site. When the explosion occurred, the debris was projected over the heads of those workers in the vicinity. No injuries were reported. 15. Calpine's investigation report of the Wolfskill incident identified several factors determined to be causal to the explosion, including that safer alternative means of cleaning the fuel gas piping were not used. The report states: "Use of natural gas is convenient, but certainly is not the only method for cleaning the pipes. Other Calpine facilities do not allow the use of natural gas for such purposes and instead use compressed air." 4 Lees, F.P. Loss Prevention in the Process Industries— Hazard Identification, Assessment and Control; Oxford, UK: Butterworth Heinemann, 1996; Vols. 1, 2, 3. 4 16. Another natural gas blow incident occurred in October of 2001 , during the commissioning of fuel gas piping at a FirstEnergy power generation station in Lorain, Ohio. The fuel gas piping leading to the turbine was cleaned through the use of an air blow, pigging, and finally a high pressure natural gas blow. The incident report indicates that a relatively short, three-foot stack was installed to serve as the fuel gas outlet during the blow. Shortly after commencing the gas blow, the gas unexpectedly ignited, causing a flame to shoot approximately 30 to 40 feet into the air from the stack outlet. Personnel immediately shut off the gas flow to extinguish the fire. No injuries resulted, but the fire caused damage to nearby electrical cables. Investigators concluded that the gas was most likely ignited by a metal particle exiting the piping during the blow which impacted a nearby metal surface, causing a spark. Gas outlet stacks for subsequent blows were increased to 16 feet in height in order to rise above nearby metal structures. Industry Practices and Safer Alternative Methodologies 17. Natural gas power plants generate electricity with combustion turbines that use natural gas as fuel. Piping from a natural gas supply line to the turbine must be installed as part of the construction process. When new piping is installed, debris such as rust, welding slag, or other foreign material that may have been introduced into the piping during construction can remain. Common practice is to clean the piping after it is installed to ensure that no significant debris remains that, upon startup, could damage the gas turbine (Figure 3). • _ ; , .t 4 . ,vi • ar a► r IV c''. Figure 3. The cleaning of fuel gas piping at the Kleen Energy site on January 30, 2010, one week prior to the incident; a "gas blow" method was used to remove debris from the piping. The brown cloud seen here is indicative of debris being blown from the line. 5 18. Turbine manufacturers typically require power plants to meet fuel piping cleanliness standards as part of the turbine warranty requirements. Cleanliness criteria are usually met by demonstrating that the number of impact marks made on a target placed in the flow of the natural gas blow by debris exiting the piping falls below pre-determined limits and sizes. The targets can be made of a variety of materials, including plywood or metal strips. Approximately half of power plants coming online between 2010 and 2015 have already reported the turbine manufacturers they intend to use.5 Six turbine manufacturers —General Electric (GE), Siemens, Solar, Mitsubishi Power Systems, Pratt& Whitney,and Rolls- Royce—are currently expected to supply 100 percent of the reported gas turbines.6 19. In a recent industry survey conducted with the cooperation of the Combined Cycle Users' Group (CCUG)in April 2010,the CSB learned that half of the respondents substitute the use of gas blows with a variety of other techniques to clean newly installed fuel gas piping,including pigging with air or nitrogen, air blows,nitrogen blows, steam blows,water, and chemical cleaning. Although these alternative methodologies are inherently safer from a fire or explosion hazard perspective,use of a natural gas blow is reported by respondents as the primary method to clean newly installed fuel gas piping. At the Kleen Energy site, Siemens,the turbine manufacturer, recommended both natural gas and air blows as acceptable methods for the cleaning of fuel gas piping. 20. About half of survey respondents have no technical basis for determining the natural gas flow needed to adequately clean the piping during a natural gas blow. The lack of a technical evaluation can result in substantially greater quantities of released natural gas than major turbine manufacturers recommend to clean the piping. 21. Companies that do a technical evaluation prior to cleaning newly installed fuel gas piping commonly refer to a technical criterion called the Cleaning Force Ratio (CFR). The CFR is a ratio that expresses the momentum of the gas used to clean the piping with respect to the normal natural gas flow design conditions. The technical concept assumes that if the momentum of the cleaning gas used in a gas blow is greater than the momentum of the natural gas during normal operation,no debris should remain in the piping that could be picked up by the natural gas flow when the turbine is operating. Turbine manufacturers vary the recommended target for the CFR, but the CSB observed a range from 1.0 to 2.0. r Plaits World Electric Power Plants Database, 2010. http://www.nJatts.com/Products.aspx'?xmlFile=worldelectricpowerplants*letabase.xm I&commodityNam e =&category=PriceAssessmentlndices&productreme=W ald%20Electric%20Power%20Plants%20Databa se. 6[bid 'Pigging is a process where a device is propelled though a pipeline.The propelled device is commonly referred to as a"pig,"and the propellant is typically a gas or liquid. When the pig is used to mechanically scrape and clean the inside of the pipe,it is sometimes called a"cleaning pig" 6 22. Siemens provided a recommended CFR target of 2.0 in its requirement for the fuel gas system, but no clear upper limit was specified. The natural gas flow data for the day of the incident indicate that the CFR target for the fuel gas piping at the Kleen Energy site was greatly exceeded and, as a result, significantly more natural gas was released than was actually needed to remove debris from the pipings mg• 23. Air blows and nitrogen blows perform the same cleaning function as natural gas blows. According to several major turbine manufacturers,the recommended CFR can easily be obtained using either air or nitrogen. However,the CSB notes that nitrogen can present an asphyxiation hazard.9 Both air and nitrogen blows have an inherent safety advantage in that no flammable gas cloud would be developed. 24. Mother cleaning method is pigging. While fuel gas can be used as the motive fluid to force the pig through the piping, air or nitrogen is commonly used. This technique—when conducted with air or nitrogen—is inherently safer than fuel gas blows to prevent fires and explosions. 25. Liquid cleaning with water or chemicals is also sometimes used to remove rust or other debris from piping. These techniques do not necessarily remove the larger debris, and a fairly common practice is to follow a chemical or water cleaning with a natural gas, air,or nitrogen blow to satisfy the turbine manufacturer cleanliness particle impact testing. 26. For the power plants being built between now and 2015 that have reported the turbines they intend to use, GE will supply 63 percent of the gas turbines.]°GE has been an industry leader in moving to recommend air blows as a safer alternative method and states that natural gas blows are not the preferred method to clean fuel gas piping. Following the Kleen Energy tragedy,GE's policy is to prohibit its employees from being onsite while a customer conducts a natural gas blow. The policy also states that GE itself will not conduct a natural gas blow unless no other satisfactory method is available. Exceptions to either aspect of this policy can be made only with approval of high-level GE management. 8 Determining the CFR of a piping system is complex. The calculated CFR for a given system will vary for a variety of reasons:the gas travels between different sized piping,the design flow rate changes, pressure drops,or the gas temperature changes. For the system at Kleen Energy just downstream of the isolation block valve where the gas was introduced,the CSB estimates a CFR of approximately 10. As the gas travels through the system towards the vent pipe,the CFR is expected to increase to values greater than 50.To calculate the CFR used at Kleen on February 7,the CSB estimated an inlet pressure just downstream of the isolation valve of 300 psig;the design flow rate changed from about 200,000 lbs/hr at the isolation block valve to approximately 72,000 lbs/hr just prior to the vent;the actual flow rate was approximately 470,000 lbs/hr;and the inlet gas temperature downstream of the isolation block valve was 18°F. 9 The CSB produced a Safety Bulletin and video on the hazards of nitrogen: http://www.csb.gov/investigations/detail.+ px7SID=77&Type=2&pg=1&F Investigationld=77. 10 Plaits World Electric Power Plants Database, 2010. lute://www.nlatts.com/Products.aspx?xm lFile=w orldelectricv o werplantsdatabase.xm l&com moditvName= &categorv=PriceAssessmentIndices&produetneme=World%20Electric%20Power%20Plants%20Database 7 27. The CSB has not identified a scenario where natural gas blows are necessary to clean fuel gas piping. 28. The independent,nonprofit Electric Power Research Institute, Inc. (EPRI) conducts research and develocment relating to the generation,delivery,and use of electricity for public benefit.' A review of publicly available technical documents from EPRI indicates that the organization does not provide guidance on safe methods to clean fuel gas piping. Hazards of Releasing Natural Gas Near Work Areas 29. Natural gas blows release large quantities of flammable gas near work areas, which can pose significant safety risks to workers. 30. Methane,the primary component of natural gas, is extremely flammable with a National Fire Protection Association(NFPA)flammability rating of"4,"the designation indicating the highest degree of hazard. It has a lower explosive limit (LEL)of 4.4 volume percent and an upper explosive limit of 16.5 volume percent in air. Methane can readily form explosive mixtures that are easily ignited when mixed with air. Methane is also an asphyxiant and may displace oxygen.t2 31. In any natural gas blow,flammable mixtures will unavoidably occur downstream of the vent outlet. To minimize the extent of the flammable atmosphere, a complex technical evaluation of various factors is necessary, including height, location and orientation of the vent pipe, velocity and density of the natural gas being discharged, potential sources of ignition, personnel location,wind speed, and a dispersion analysis to verify that the natural gas will rapidly dissipate. The complex requirements for discharge design support the use of safer methods to clean fuel gas piping. 32. The CSB has examined a number of natural gas blow procedures. Several serious deficiencies were noted that could result in unsafe work practices, including • A lack of a technical evaluation of the vent piping to ensure adequate air mixing and that the release is directed to a safe location, • Ill-defined instructions to control or eliminate potential ignition sources, and • Failure to recognize that the natural gas blow itself may provide a source of ignition from a potential static charge accumulation in the vent pipe or from 11 EPRI brings together its scientists and engineers,as well as experts from academia and industry,to help address challenges in electricity,including reliability,efficiency,health,safety,and the environment. EPRI's members represent more than 90 percent of the electricity generated and delivered in the U.S. (www.epri.com) 12 Canadian Centre for Occupational Health and Safety. http://www.ccohs.ca/oshanswers/chemicals/chem_profiles/methane/working met.html (accessed June 3, 2010). 8 discharged debris sparking upon impact with objects downstream of the ejected natural gas. 33. Well-recognized industry consensus safety guidelines emphasize the importance of eliminating hazards when feasible. The American National Standard for Occupational Health and Safety Management Systems, ANSI/AIHA Z10-2005, defines minimum requirements for safety management systems to reduce injuries and fatalities. The standard states "[w]hen controlling a hazard[,] the organization should first consider methods to eliminate the hazard or substitute a less hazardous method or process."This basic process safety system concept is also well-established by the Center for Chemical Process Safety(CCPS)publications on inherent safety.14 The CCPS documents that Inherent Safety is an approach focused on eliminating or reducing the hazards associated with a set of conditions. A process is inherently safer if it reduces or eliminates hazards and if this reduction or elimination is permanent and inseparable. An inherently safer process should not be viewed as "absolutely safe,"as all processes have some element of risk. One important element of inherent safety is substitution, where a less hazardous material is substituted for a more hazardous material. In the case of natural gas blows, cleaning fuel gas piping can be made inherently safer by substituting the more hazardous natural gas with a less hazardous material, such as air, to eliminate the potential for fire and explosion. 34. The possibility of catastrophic consequences, a complex technical evaluation, the extreme difficulty in eliminating and controlling all ignition sources, and the common use of safer methods are compelling reasons to implement safer alternatives to flammable gas releases. Codes and Standards 35. The National Fire Protection Association (NFPA)and the American Gas Association(AGA)have adopted fire safety consensus code requirements for installing fuel gas piping systems and natural gas usage equipment in National Fuel Gas Code(NFPA 54/ANSI Z223.1). The International Code Council (ICC) has adopted the same requirements in the International Fuel Gas Code. These requirements are commonly adopted as regulations by various state and local governmental entities throughout the U.S. More than 35 states have adopted NFPA 54, and Connecticut has adopted the 1996 version of NFPA 54. 36. NFPA 54 and the International Fuel Gas Code broadly address fuel gas piping system safety including requirements for design, installation, operations, and maintenance. The codes do not address safe practices for cleaning fuel gas piping. "Lees,F.P.Loss Prevention in the Process Industries—Hazard Identification,Assessment and Control; Oxford,UK:Butterworth Heinemann,Oxford, 1996; Vols. 1,2,3. 14 Center for Chemical Process Safety(CCPS).Inherently Safer Chemical Processes—A Life Cycle Approach;American Institute of Chemical Engineers(AIChE),2009. 9 Moreover,the codes explicitly exempt from coverage fuel gas piping in power plants and piping operated at a pressure of more than 125 psig. 37. NFPA 37,Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, establishes criteria for minimizing the hazards of fire while installing and operating stationary combustion engines and gas turbines. However, NFPA 37 provides no guidance about how to effectively clean new gas piping to gas turbines without creating a fire and explosion hazard and endangering workers. The NFPA's internal interpretation of this standard is that it is not applicable to the type of piping that was being cleaned in the Kleen Energy incident.s 5 38. American Society of Mechanical Engineers (ASME)Code B31.1-2007, Power Piping, provides guidance for constructing the temporary piping used to clean or flush foreign material from piping systems. The standard references cleaning out piping by using air or steam but does not explicitly prohibit using natural gas. The standard offers no guidance about the technical or safety aspects for conducting natural gas blows. 39. FM Global Property Loss Prevention Data Sheets for Power Generation include document 7-54,"Natural Gas and Gas Piping."This document calls for the use of air or inert gas to clean or test piping, but allows for the use of fuel gas when the pressure is 0.5 psig or less. 40. NFPA 850,Recommended Practice for Fire Protection for Electric Generating Plants and High Voltage Direct Current Converter Stations, provides fire hazard control recommendations for the safety of construction and operating personnel, the physical integrity of plant components, and the continuity of plant operations. Under NFPA 850,natural gas piping should comply with NFPA 54,National Fuel Gas Code; NFPA 55, Compressed and Cryogenic Gases; and ASME B31.1, Power Piping. NFPA 850 references NFPA 54 even though power plants have been exempted from that standard. NFPA 850 does not address safe practices for cleaning power plant fuel gas piping. As a recommended practice,the provisions of NFPA 850 are not safety requirements and are voluntary in all jurisdictions. Other Natural Gas Release Incidents 41. There is an underlying common theme among the tragic incidents at Kleen Energy, the ConAgra Foods Slim JimTM plant explosion in North Carolina, and many other flammable gas-releasing incidents: companies should use safer methods and not release flammable gases in close proximity to ignition sources and workers. 15 The NFPA's position is that NFPA 37 applies only to gas piping downstream of the final block valve before the gas turbine. At the time of the Kleen incident,the piping being cleaning and vented was upstream of the block valve.However,this distinction is not explicit in the standard. 10 42. On June 9, 2009,the ConAgra Foods production facility in Garner, North Carolina,experienced a catastrophic natural gas explosion that caused four deaths, three critical life-threatening burn injuries, an amputation, and other injuries that sent 67 people to the hospital. The explosion caused serious structural damage to the approximately 87,000 square foot south packaging and warehouse area of the Gamer plant. The walls and roof collapsed and piping from the plant's large ammonia-based refrigeration system was damaged, causing toxic anhydrous ammonia gas to be released to the atmosphere. 43. At the time of the explosion,natural gas was being purged from a line connected to a newly installed water heater within a central location of the ConAgra Foods facility. This was not a pipe cleaning activity, but parallels the Kleen Energy incident in that fuel gas piping was installed to supply new combustion equipment at both locations. Additionally, flammable natural gas was intentionally released to the atmosphere in the presence of ignition sources and workers. 44. A number of other similar natural gas purging incidents have occurred: the Dearborn, Michigan, Ford Rouge power plant explosion in 1999 (six fatalities); the San Diego, California, Hilton Hotel explosion in 2008 (14 injuries); and the Cheyenne, Wyoming, hotel construction explosion in 2007(two severely burned). 45. The CSB determined that the version of NFPA 54 that existed at the time of the ConAgra explosion did not require fuel gas piping to be vented safely outdoors. As a result,the CSB made an Urgent Recommendation to NFPA and AGA to enact temporary and permanent changes to NFPA 54 to require that purged fuel gases be vented to a safe location outdoors away from personnel and ignition sources. 46. In response to the CSB Urgent Recommendation addressing the history of serious natural gas purging incidents,the full NFPA 54 committee voted unanimously in February 2010 to adopt stricter standards in the form of a Tentative Interim Amendment(TIA)requiring that larger fuel gas piping systems be purged directly to a safe location outdoors away from workers and sources of ignition. However, in April 2010,the full NFPA 54 committee failed to pass the TIA during a required second ballot. Recently in June 2010, a revised TIA passed. Further action by NFPA is expected in August 2010. Regulatory Coverage 47. The Occupational Safety and Health Administration(OSHA)has issued general industry and construction regulations16 that address flammable gas safety, including standards on Hydrogen [1910.103];Acetylene [1910.102]; and the 16 While the Kleen Energy incident occurred during construction activities,cleaning of power plant fuel gas piping can occur under circumstances that are regulated by either OSHA general industry or construction standards. 11 Storage and Handling of Liquefied Petroleum Gases [1910. 110 and 1926. 153] . However, OSHA has not issued a standard that addresses the safe handling of natural gas or the hazards of methane — the primary component of natural gas. 48. The consumption of natural gas as a fuel in the U.S. far exceeds that of liquefied petroleum gases (LPG) and ethane (Figure 4).17,18 Natural gas usage exceeds that of propane, the second most used fuel gas, fifteen times over; however, natural gas is one of only two fuel gases not regulated by OSHA (Figure 4). Annual U . S. Consumption of Fuel Billion BM Gases (2008) 25,OOO,OOO 20,000,000 - II Non-OSHA Regulated 15,OOO,OOO - In OSHA Regulated 1O,OOO,OOO - 5,OOO,OOO - * * 0 Natural Gas Propane Ethane Butane Isobutane Figure 4. Natural gas is used far more, then the regulated fuel gases shown here. 49. The use of natural gas also far exceeds the use and/or production of other flammable gases in the U.S., including hydrogen and acetylene. However, unlike hydrogen and acetylene, it remains unregulated by OSHA (Figure 5).19,20,21 Eighty percent of natural gas is used in sectors covered by OSHA; 49 percent is used in 17 Energy Information Administration (EIA). Office of Coal, Nuclear, Electric and Alternate Fuels. Natural Gas Consumption by End Use. May 2010. httn://www.eia.doe.aov/dnav/na/na cons sum dcu nus a.htm (accessed June 7, 2010). 18 ETA. Product Supplied. June 2009. http://www.eia.doe.gov/dnav/pet/pet_cons_psup_dc_nus_mbbl_a.htm (accessed June 7, 2010). 19 Ibid. footnotes 12 and 13. 20 EIA. The Impact of Increased Use of Hydrogen on Petroleum Consumption and Carbon Dioxide Emissions, SR/OIAF-CNEAF/2008-04, Aug. 2008. www.eia.doe.gov/oiaf/servicerpt/hydro/pdf/oiafcneaf(08)04.pdf, (accessed June 7, 2010). 21 Davis, S; Schlag, S.; Funada, C. Chemical Economics Hanabook: SRI Consulting, 2008. http://www.sriconsulting.com. 12 industrial and commercial applications and 31 percent is used in power plants. The remaining 20 percent is residential.22 Annual U . S. Production and Consumption Billion BTU of Flammable Gases (2008) 25,000,000 20,000,000 a Non-OSHA Regulated 15,000,000 OSHA Regulated 10,000,000 - 5,000,000 0 Natural Gas Propane Hydrogen Ethane Butane Acetylene Isobutane Figure 5. Fuel gas consumption and hydrogen and acetylene production 50. The OSHA standard for LPG was based on the 1969 edition of NFPA 58. The most recent (2008) edition of NFPA 58 contains safe venting provisions that are more protective than OSHA's LPG Standard. These include additional provisions for safe purging of LPG vapor, requiring that vented product be conveyed outdoors "under conditions that result in rapid dispersion" or else combusted. 51. OSHA has issued the Electric Power Generation, Transmission and Distribution standard [ 1910.269(a)( 1 )(ii)(A)] that covers the operation and maintenance of electric power generation; however, the standard does not apply to the construction work being performed at Kleen Energy on the day of the incident. 52. OSHA's regulatory scheme provides requirements for controlling ignition sources in hazardous locations that may have flammable atmospheres [e.g., 1910.307 Hazardous (classified) locations and 1910.252 Welding, Cutting and Brazing]. However, OSHA's regulations that are otherwise applicable to this incident do not expressly prohibit the planned release of flammable gas in the vicinity of workers. OSHA's Process Safety Management (PSM) Standard [ 1910. 119 and 1926.64] addresses requirements for preventing the consequences of the catastrophic release of highly hazardous chemicals, including flammables. The PSM Standard, however, exempts flammable liquids or gases that are used solely for workplace 22 McDowell, B. "Natural Gas 101 & Current Industry Issues," American Gas Association, http://www.aga.org/NR/rdonlyres/A66D328D-0D50-4770-BDFC-84D342207381/0/0605NG 101 .pdf retrieved June 23, 2010. 13 fuel consumption, which was the case at Kleen Energy, where the design intent was to use natural gas as a fuel,23 53. The Connecticut Governor's Commission investigating the Kleen Energy explosion also found that, although the construction project was heavily regulated by a variety of agencies, no agency regulated the process used —or any process that might be used such as gas purging—to clean the natural gas pipeline that was the source of the explosion. 54. Other U.S. and international workplace safety regulations not only require that ignition sources in hazardous areas be eliminated, but also prohibit workers from being exposed to a work environment with a potential flammable atmosphere. California construction safety regulations24 require that"flammable vapors shall be controlled so as to avoid hazard to workers."The California construction regulations define adequate ventilation for flammable gases as that which is sufficient to keep the concentration of flammable gas below 20 percent of the LEL.25 The majority of Canadian provinces prohibit work activity in an area if more than 20 percent of the LEL of a flammable is present in the atmosphere. OSHA has no similar general workplace requirements protecting workers from exposure to flammable atmospheres. 55. At the Kleen Energy site,no safety meeting was conducted,nor was the gas blow procedure reviewed, with the pipe cleaning crew before work began on February 7. Safety meetings and procedural reviews provide personnel opportunities to discuss potential safety risks involved in planned work and suggest safer alternatives. Presently,there are no OSHA regulatory requirements for workers to participate in developing procedures or training related to fuel gas safety. 56. The Environmental Protection Agency(EPA)has reporting regulations for hazardous substances that pose a potential threat to public health,welfare, and the environment, as listed in 40 CFR 302.4. The reportable quantities are based on several intrinsic characteristics, including ignitability; however,methane, which is highly flammable, does not appear in 40 CFR 302.4. 57. Individual states can implement their own environmental reporting requirements and at least two, Louisiana and Michigan, have specific rules concerning releases of natural gas. In Louisiana,releases greater than 1.0 but less than 2.5 million 23 The PSM standard requires that operating procedures such as those for start-up and temporary operations "provide clear instructions for safely conducting activities,"including hazards of the chemicals used in the process and"precautions necessary to prevent exposure."Preliminary CSB analysis indicates that despite the occurrence of a catastrophic incident from the release of a highly hazardous chemical (flammable gas),the amount of flammable gas onsite in the piping would not have met the threshold quantity of 10,000 pounds that would trigger PSM coverage. However,a much larger quantity of flammable gas than 10,000 pounds was released to the atmosphere the morning of the incident. 24 California Code of Regulations,Title 8,Section 1534,Construction Safety Orders,Flammable Vapors. 25 The Lower Explosive Limit,LEL,is the concentration of a combustible material in air capable of propagating a flame in the presence of an ignition source(California Code of Regulations,Title 8,Section 1504,Construction Safety Orders,Application). 14 cubic feet in volume require a permit, but no controls. Releases greater than 2.5 million cubic feet require "flaring"26 the natural gas. In Michigan,when the release of natural gas exceeds 1.0 million cubic feet,"[t]he venting includes, at a minimum, measures to assure safety of employees and the public [and to] minimize impacts to the environment...."The 23 other states the CSB contacted indicated that they have no specific regulations concerning natural gas releases. Standard and Basis for Urgent Recommendations 58. Under 42 U.S.C. §7412(r)(6)(C)(ii),the U.S. Chemical Safety and Hazard Investigation Board is charged with"recommending measures to reduce the likelihood or the consequences of incidental releases and proposing corrective steps to make chemical production,processing,handling and storage as safe and free from risk of injury as is possible ...." 59. Board procedures authorize the development of an urgent safety recommendation "Wan issue is identified during the course of an investigation that is considered to be an imminent hazard and has the potential to cause serious harm unless it is rectified in a short timeframe,or a hazard is identified that is likely to exist in a large segment of industry such that the probability of an incident is significant." 60. General contracting companies and commissioning agents surveyed by the CSB acknowledge that the most common practice to clean fuel gas piping is with natural gas. From a fire and explosion perspective,releasing large volumes of natural gas in the vicinity of workers or ignition sources is inherently unsafe. 61. Approximately 125 power plants will commission new natural gas-fired combustion turbines between 2010 and 2015.27 Figure 6 depicts the location density of these various plants across the U.S. 26 Flaring is a process by which combustible gas is directed to disposal equipment so that it may be destroyed by burning rather than being released to the atmosphere. n Platt World Electric Power Plants Database, 201 a http://www.platts,com/Produc ts.aspx?xmIFile—worldelectricpowetplantsdatabase.xm l&commodityName =&category=PriceAssessmentlndices&Droductnam e=Wald%20filecttic%20Power%20Plants%20Databa se. 15 • jS. f I \ pr--- rJ _ � Number of Gas Fueled • Powerplanb _ • :.j 0 3/4 umt -8 X11 - 23 Figure 6. Location density of power plants with new natural gas-fueled combustion turbines (2010-2015) 62. The CSB has documented previous incidents where flammable gas was released in the vicinity of workers and ignition sources that led to serious fires and explosions.28 63. Companies continue to conduct natural gas blows after the Kleen Energy explosion. The CSB contacted 33 natural gas power generation plants currently under construction or planned to be constructed in the near future, and learned of two plants that have conducted a natural gas blow since the Kleen Energy incident and several others that are actively planning natural gas blows. Other plants the CSB contacted indicated that, because of the incident, they will not conduct a natural gas blow or will look into safer alternatives. 64. Well-recognized safety guidance requires that safety hazards be eliminated where feasible. Safer alternatives to natural gas blows, such as using air, nitrogen or pigging with air, are commonly practiced. GE and Siemens, two major turbine manufacturers, acknowledge that safer alternatives, such as using air, are just as effective as natural gas for cleaning fuel gas piping. 65. The electric power generation sector and related industry associations do not currently operate a safety standards development program or publish industry- recognized safety standards. No recognized good practice safety standards or technical guidelines address the conduct of cleaning power plant fuel gas piping. 28 Paragraphs 12, 16, 41, and 44 of this Urgent Recommendation document these releases. 16 66. Although the use of natural gas far exceeds that of other regulated flammable gases, OSHA has not issued a standard that addresses the safe handling of natural gas or that prohibits the release of fuel gas in the vicinity of workers and/or ignition sources. Accordingly: Pursuant to its authority under 42 U.S.C. § 7412(r)(6)(C)(i)and(ii), and in the interest of preventing the serious harm that could result if the hazards underlying the explosions at Kleen Energy, ConAgra and other related incidents are not promptly rectified,the Board makes the following urgent safety recommendations: Occupational Safety and Health Administration (OSHA) 2010-01-I-CT-U R1 Promulgate regulations that address fuel gas safety for both construction and general industry. At a minimum: a. Prohibit the release of flammable gas to the atmosphere for the purpose of cleaning fuel gas piping. b. Prohibit flammable gas venting or purging indoors. Prohibit venting or purging outdoors where fuel gas may form a flammable atmosphere in the vicinity of workers and/or ignition sources. c. Prohibit any work activity in areas where the concentration of flammable gas exceeds a fixed low percentage of the lower explosive limit(LEL) determined by appropriate combustible gas monitoring. d. Require that companies develop flammable gas safety procedures and training that involves contractors, workers, and their representatives in decision-making. National Fire Protection Association (NFPA) 2010-01-I-CT-UR2 Enact a Tentative Interim Amendment and permanent changes to the National Fuel Gas Code(NFPA 54/ANSI Z223.1)that address the safe conduct of fuel gas piping cleaning operations. At a minimum: 17 a. Remove the existing NFPA 54 fuel gas piping exemptions for power plants and systems with an operating pressure of 125 pounds per square inch gauge (psig)or more. b. For cleaning methodology, require the use of inherently safer alternatives such as air blows or pigging with air in lieu of flammable gas. American Society of Mechanical Engineers (ASME) 2010-01-I-CT-UR3 Make appropriate changes to the 2012 version of Power Piping, ASME B31.1,to require the use of inherently safer fuel gas piping cleaning methodologies rather than natural gas blows. At a minimum, for the cleaning or flushing methods discussed in B31.1 paragraph 122.10, require the use of inherently safer alternatives such as air blows and pigging with air as the motive force in lieu of flammable gas. Major Gas Turbine Manufactures General Electric 2010-01-I-CT-UR4 Siemens 2010-01-I-CT-UR5 Solar 2010-01-I-CT-UR6 Mitsubishi Power Systems 2010-01-I-CT-UR7 Pratt& Whitney 2010-01-I-CT-URN Rolls-Royce 2010-01-I-CT-UR9 Provide to your customers: a. Comprehensive technical guidance on inherently safer methods for cleaning fuel gas piping, such as the use of air or pigging with air. b. Comprehensive Cleaning Force Ratio(CFR) guidelines, specifying both the upper and lower limits required to obtain satisfactory cleaning for the fuel gas piping for purposes of the warranties of the turbines. c. Warnings against the use of fuel gas to clean pipes. 18 General Electric 2010-01-I-CT-UR10 Solar 2010-01-I-CT-URI1 Siemens 2010-01-I-CT-UR12 Mitsubishi Power Systems 2010-01-I-CT-UR13 Pratt& Whitney 2010-01-I-CT-UR14 Rolls-Royce 2010-01-I-CT-UR15 Work with the Electric Power Research Institute to publish technical guidance addressing the safe cleaning of fuel gas piping supplying gas turbines. At minimum: a. For cleaning methodology, require the use of inherently safer alternatives such as air blows and pigging with air in lieu of flammable gas. b. Provide technical guidance for the safe and effective use of alternative methods for cleaning such as air and pigging with air. The Governor and Legislature of the State of Connecticut 2010-01-I-CT-UR16 Enact legislation applicable to power plants in the state that prohibits the use of flammable gas that is released to the atmosphere to clean fuel gas piping. 2010-01-I-CT-UR17 Adopt the current version of NFPA 54 as amended pursuant to 2010-01-I-CT-R2. The Board further authorizes and directs the chairperson to send correspondence to the governors of the other 49 states urging them to review the Board's fmdings concerning the explosion at Kleen Energy,the Board's recommendations to Connecticut, existing state regulations concerning natural gas safety, and to enact any necessary changes to state regulations and codes to prohibit the release of natural gas to the atmosphere during pipe cleaning operations at power plants and other similar facilities. Electric Power Research Institute (EPRI) 2010-01-I-CT-UR18 Work with the six turbine manufacturers identified in this document—General Electric, Siemens, Solar, Mitsubishi Power Systems, Pratt& Whitney, and Rolls-Royce—to publish technical 19 guidance addressing the safe cleaning of fuel gas piping supplying gas turbines. At minimum: a. For cleaning methodology, require the use of inherently safer alternatives such as air blows and pigging with air in lieu of flammable gas. b. Provide comprehensive technical guidance on inherently safer methods for cleaning fuel gas piping, such as the use of air or pigging with air. 20 Po.•H ZAR, -�% se 10.4744 C • 4W VI CASE STUDY 0 . ; t .4 .in > �& 2 '''••. .6.;i41•''d� V'n Explosion and Fire in West Carrollton , Ohio 2009-10-I-OH JULY 21 , 2010 (Four Workers Injured, Community Damage) , , --- y This case study examines an • �+J' explosion and fire at the Veolia ES it "t'" , t 4 _, . at<' .F _ ~' f 'I fr �c Technical Solutions, LLC, facility in ie '. li l' , .• :A M/..-4) try. West Carrollton, Ohio, that severely • • • di ; _ • S i •- Sr �+ injured two workers and slightly riot/ 1. _� •�. , f w �. injured two others. Eight structures at pe - J t ' r,- .. . ~''' / . • t' the plant sustained damage, as did 4! 0 ' or, sr." approximately 20 residences and . " •� llit ' rf t . ; jy1,01r. itti ,l. businesses offsite. ~`, fit — { "e + �• e ,•11- •• I i Ink, ,...----:, 'r-*.. ---- - as. M'ke.).4,12-: -- >‘44:' t•� r fit. l• 40 . _, ,'•hr � a t .�' •.tip.y. • "a i s. .'; :. - 4.' i . • .4- •••• pie _ - c - 6 Photo Courtesy of Ohio State Fire Marshal INSIDE . . . Veolia Technical Solutions , LLC Introduction West Carrollton, Ohio Process Discussion May 4, 2009 The Incident Consequences Key Issues : Emergency Response • Unsafe Building Siting Findings Analysis • Atmospheric Relief Systems Recommendations • Plant Emergency Procedures Veolia ES Technical Solutions,L.L.C. Case Study JULY2010 1 .0 Introduction At about 12:07 a.m. on May 4, 2009, highly about 72 workers on the day of the incident. Six flammable vapor, released from a waste employees were at work on the night of the recycling process, ignited and violently incident. Veolia is a member of the exploded, severely injuring two employees and Environmental Technology Council (ETC), a slightly injuring two others at Veolia ES national trade association of commercial Technical Solutions, LLC. Multiple explosions environmental firms that recycle, treat, and afterward significantly damaged every structure dispose of industrial and hazardous waste. on the site. Residences and businesses in the surrounding community also sustained The CSB issued two recommendations to ETC considerable damage. The fire was declared as the result of an investigation of a fire in 2006 under control by 10:38 a.m. that day. at a hazardous waste facility located in Apex, North Carolina. ETC has not acted upon 1 .1 Veolia Corporation either of these recommendations to date. The West Carrollton facility opened in 1979 as Governed by U.S. Environmental Protection Solvent Resource Recovery and, after several Agency (EPA) regulations authorized by the name changes, became Chemical Waste Resource Conservation and Recovery Act Management (CWM) Resource Recovery in (RCRA), Veolia is a state-permitted treatment, 1988. In 1999, Vivendi, a French company storage, and disposal facility (TSDF). The site purchased the facility as part of a larger was subject to inspections by the Ohio EPA acquisition and transferred the assets to Onyx twice a year, and customers audited between 20 Environmental Services, L.L.C. (OES). and 40 times a year. The site provided the On July I, 2006 the site was renamed Veolia ES following services to waste generators: Technical Solutions, L.L.C. (VESTS)—a subsidiary of Veolia Environmental Services • Fuel Blending: Received flammable and North America Corp. (VESNA). VESNA is a combustible waste streams (liquids, solids, publicly traded subsidiary of Veolia and sludge), consolidated them into Environnement, which employs more than marketable waste-derived fuels, and shipped 300,000 worldwide. them for burning in energy-recovering cement kilns. Bulk and containerized wastes 1 .2 Company Background1 arrived in liquid, solid, or sludge/slurry form. The Veolia facility is approximately 7 miles • Solvent Recovery: Distilled and reclaimed southwest of Dayton, Ohio, and is located on liquid waste solvents that arrived in loads. Infirmary Road, 0.7 miles north of the The facility had three distillation units that intersection with Farmersville West Carrollton produced usable solvent from this waste Road. The surrounding land is used for material. residential, industrial, and farming purposes. • Waste Consolidation: Consolidated like materials into larger containers, usually 55- The company provided hazardous waste services gallon drums. If possible, the consolidated for industrial and municipal customers. The material was blended or recovered onsite; Veolia site, an estimated 20 acres, employed otherwise, it was transported to other locations. • Waste Material Transfer: Received, Part of the facility is being rebuilt and some is still stored, packaged, and transferred waste in operation,but for the sake of consistency,and to which did not require treatment, fuel avoid confusion,past tense will be used throughout blending,or disposal. this document. 2 Veolia ES Technical Solutions, L.L.C. Case Study JULY2010 - JY Process Area • Maintenance "' : •• . Building t, ii1 fI3 .4. _ . ,. .,. is — , Decant re- •u -� , tI ir- r !_ P" ' Building H. _ IS 1 'IA ,1.- ‘, e I ti — 44 - 41%-h. , ; ic., . fri ir , iii , ii, , , , ,.• irt a :‘,„, 4 ki ` r . ♦, .; Lab/Operations Building • avr_.- / it ' ''-' ,t - ki 1 , -* i Non-hazardous _ 1 41' ' Storage Building = ' 1 I f . ► � Administration " Building - . M_ I ,- Drum Storage L ;. - • . Building Figure 1. Aerial view of the Veolia facility (Montgomery County, OH GIS Photo) wall of this building was less than 30 feet from 1 .3 Facility Description the operating units. The administration building, located about 500 Employees occupied a number of structures at feet south of the operating plant, provided office the site depending on the time of day. The and meeting space for plant management, lab/operations building and the administration technical, accounting, environmental health and building were the two with the most employees. safety, and other personnel. The lab/operations building was a multi-use The remaining structures were the decant, drum structure that served as the primary workstation storage, non-hazardous waste processing, and for lab technicians, lab managers, production maintenance buildings. The processing area clerks, plant operators, and supervisors. The consisted of two tank farms and three solvent building also housed a control room, recovery units. break/dining area, laboratory, and locker rooms. Eight offices were contained within the building. Three boilers were located in the northwest section of the lab/operations building. The north 3 Veolia ES Technical Solutions, L.L.C. Case Study JULY2010 2.0 Process Discussion onsite distillation consisted of plasticizers, resins,pigments,and residual solvents. Tanker trucks were unloaded directly into bulk 2.1 Solvent Recovery Process storage tanks (dirty tanks) at the trailer Description containment areas. Drums were unloaded into receiving areas for temporary staging. Waste was then decanted into bulk storage tanks or Veolia processed hazardous and non-hazardous repackaged for shipment offsite. Veolia either waste products at the West Carrollton site. The returned clean solvent to the generator for reuse facility received waste solvent in bulk tanker or sold the product to other industrial users after trucks and drums. The waste streams received purifying it by distillation. Veolia also for recovery were dirty or spent solvents from transported non-distillables to an offsite industrial generators. Typical solvent blends permitted hazardous waste facility for consisted of aliphatic hydrocarbons, chlorinated combustion either in a supplemental fuels hydrocarbons, esters, ketones, and alcohols. The program or in a hazardous waste incinerator for residue, or "still bottoms," that remained after safe destruction. 680 C-15 DRY D-9 CD II 6 a O DOCK f- _ C44 C-5 CE MOL D-7 D-0 SIEVE C 1 DS O OSO 0 CD C-12 O UNfT UNIT UNIT D� CIID CD C-11 C-1 C 2 4 9 O O D-1 D-2 F CID - - CLEAN TANKS DIRTY TANKS I DIRTY LADIES r-1 CHANGE CHANGE }' ROOM ROOM 113 N #1 CONTROL LAB LAB -_- ROOM BOILER ROOM JI LAB/ LI- / I OPERATIONS BUILDING OFFICE OFFICE FFICE � _ O 1 LOCKERS LU CH CHANGING ROOM OFFICE OFFICE LOBBY OFFICE OFFICE ,,OFFICE N YI Figure 2.Plot plan of Units 1,3,and 4; clean and dirty tanks;and the lab/operations building(not to scale) Veolia recovered and recycled waste solvents to solvents were unloaded into tanks in the dirty 95 to r99e percent concentration. Twenty-three tank farm. Dirty tanks acted as feed tanks for the carbon steel "dirty" tanks and 16 stainless steel solvent recovery process, and clean tanks "clean" tanks ranging in capacity from 8,000 to received and stored recovered product. 20,000 gallons abutted Units 1, 3, and 4 to the A three-inch vapor-piping manifold, called the east and west, respectively (Figure 2). Incoming "vapor balance system," equalized the gas 4 Veolia ES Technical Solutions, L.L.C. Case Study JULY2010 pressure above the liquid contents when loading 3.0 The Incident and unloading the tanks. The dirty tank farm and the clean tank farm had independent vapor balance pipe systems, though the dirty tank The incident occurred at about 12:07 a.m. on vapor balance system was connected to the May 4, 2009, when highly flammable vapor molecular sieve unit and the drum disposal unit released from a waste recycling processing area at the decant building. in the dirty tank farm ignited and violently exploded, severely injuring two Veolia Units 1, 3, and 4, the three distillation units, and employees. One employee suffered first-degree one molecular sieve processed the dirty solvents. burns and a second broke his pelvis. Multiple The molecular sieve removed water from certain explosions ensued, significantly damaging a solvent streams and was connected to the dirty majority of the facility, surrounding businesses tank vapor balance system. Processed solvents and residences. were then stored in stainless steel tanks in the The two most severely injured were both in the clean tank farm. lab/operations building at the time of the Units 1 and 3 operated continuously while Unit incident. One worker was in the control room, 4 used a batch process. Unit 1 was composed of located about 25 feet from the operating unit, a thin film evaporator and condenser.2 Unit 3 when the escaping vapor ignited. He reported consisted of a wiped film evaporator, being enveloped "[in a] fireball that...went fractionating distillation column, and through the building [and that] seemed to stop as condenser.; Unit 4 used a 12,000-gallon batch fast as it started." Shortly after the first series of still, reboiler, fractionating distillation column, explosions, this worker was seen exiting the area and condenser.' One operator was responsible to a pre-arranged assembly point at the main for operating all units under the direction of a gate. West Carrollton Fire Department (WCFD) shift supervisor and a reclaim supervisor. The Emergency Medical Services (EMS) units operated 24 hours a day, seven days a immediately transported him to Miami Valley week as needed to meet production demands. Hospital. WCFD EMS examined two other Veolia Three natural gas-fired tube boilers produced employees. One, whose hands were cut after he 120-psig steam for both process use and building jumped a fence topped with barbed wire, was heat. A Therminol 55® hot oil unit provided treated and released. The second, who process heat for evaporators in Units 1 and 3. experienced breathing difficulties, was treated The facility used nitrogen to regenerate the with a nebulizer and released. molecular sieve, blanket the hot oil unit, and purge the drum disposal unit. One severely injured employee heard the sound of a release and detected a very strong odor as he left for a meal break in the area south of the lab/operations building about three minutes before the explosion occurred. He saw a white vapor cloud in the dirty tank farm advancing toward the lab/operations building. He returned 2 Thin film evaporators heat the raw material on the to the lab/operations building to notify the shift internal surface of a heated tube until the lower supervisor and other personnel, and to retrieve a boiling component starts to evaporate. respirator. When the vapor ignited, a bank of Wiped film evaporators increase evaporation or personnel lockers fell over, briefly pinning the separation of heat-sensitive liquids.Feed flows employee and breaking his pelvis. down the inside of a cylindrical vessel wall,while rotating wiper blades spread the material across the Unable to walk, the worker sought shelter wall and maintains a uniform film of the material. underneath a tractor-trailer after he dragged 4 OSHA Process Safety Management(PSM)covered himself out of the southwest door of the process. lab/operations building. When he saw flames 5 Veolia ES Technical Solutions, L.L.C. Case Study JULY 2010 advancing toward him, he continued his egress To demonstrate the rattle to the nightshift along the property fence-line on the southwest operator coming on shift, the dayshift operator portion of the facility until he found help near pressured nitrogen back through the pump the administration building about two hours after suction to the vessel serving as the source of the incident. material to the pump. An employee standing at the northwest comer of Immediately prior to the release that led to the the lab/operations building reported that the explosion, the unit operator had commenced the sound of the release subsided noticeably just shutdown of a tetrahydrofuran (THF) solvent before the first explosion. He then saw the recovery process on Unit 3 when test results double-doors of the room housing three natural indicated that the material had reached the gas-fired boilers blow open. (Two of the boilers desired azcotropic6 state. were in service at that time.)A few seconds after the first event, he saw a subsequent, larger Unit 3 was processing a THF and water mixture explosion that appeared to originate in the dirty that was stored in dirty tank 14 (D-14). The tank farm. The worker saw a flame-front that intent was to recover THF from the mixture for a extended to the north wall of the drum storage customer. The THF was transferred to a mixing building, which exhibited extensive damage tank in the clean tank farm where fresh water during post-incident inspections. was added re-dilute the mixture to 20 percent THF and 80 percent water. The THF and water Neighboring property security/surveillance mixture was decanted back to D-14 for media recorded multiple explosions after the processing in Unit 3. When the THF and water initial event. These recorded events proceeded mixture reached its azeotrope of 5.3 percent for roughly 45 minutes after the initial water in THF, further distillation was no longer explosion. effective in Unit 3 and the recovery process was transferred to the molecular sieve to break the 3. Operations at Time of azeotrope and dry the THF to a water content of 0.03 percent Incident The plant operators worked 12-hour shifts; day shifts started at 5:00 am and night shifts started at 5:00 p.m. At shift change before the incident, the dayshift operator told the nightshift operator that something had dislodged in the Unit 3 evaporator, causing an intermittent rattle in the sludge pump during his shift.' When the day shift operator noticed the unusual sound, he contacted the reclaim supervisor by phone at home, who advised him to continue operating Unit 3 as outlined in the operating plan unless the pump was disrupting plant operation. 6 An azeotrope is the threshold ratio of two or more liquids(chemicals)such that simple distillation cannot further change their composition.When two 5 The CSB investigators discovered that the cause of substances reach azeotrope,the boiled vapor has the rattling was a sheared bolt used to secure a the same ratio of constituents as the original blade in the evaporator. mixture. 6 Veolia ES Technical Solutions, L.L.C. Case Study JULY2010 Sa , presareNacuwn • aker kW 4—\ Long-bol flange 7 Yam balance Ina -- -air Imillmi. Intercomeds dirty tanks. . molecular sieve, and drum disposal unit .,I C Level motet°, •FAir„ f ; ) linew / ar ) i " i'd : 1 i I I I . �, i \L • o p ~_ �J ( a. Rpx g meniddrx • Nitrogen blow-tack todiry tank from Urn x x x • •• x x crnm Urn 1 .3 or 4 * i� 1�t x To Units 1, 3 or 4 f ♦— xC f— x x x x_ x Figure 3. Dirty tank, manifold, and relief systems After completing the run, the Unit 3 shutdown 3.2 THF Characteristics process required clearing the pipe of remaining process materials. This was accomplished by THF, a general purpose, flammable, organic back-blowing nitrogen through the circulation solvent, is a colorless, water-miscible, stable piping into the dirty tank prior to closing valves liquid. THF reacts readily with oxygen (e.g., on to isolate the tank from the operating unit. The contact with air) to form unstable peroxides vapor release occurred shortly after the unit (predominantly hydroperoxides). Adding certain operator started the flow of nitrogen back to the stabilizers inhibits the formation of peroxides. dirty tank. THF has a flammability rating of 3 in Employees present at the time of the incident accordance with NFPA 704, and is a class 1B reported that, about two minutes before the flammable liquid. explosion, they heard a loud vapor release. Some also recalled a very strong THF odor and A solution of THF in water is flammable in reported the source of the release to be in the concentrations of only 0.3 percent. Escaping dirty tank area, which is about 80 feet northeast vapors can flow along surfaces to distant of the three natural gas-fired boilers located in ignition sources and result in a flashback fire. the lab/operations building. In addition, they reported the vapor drifting back to ground level THF vapors form an explosive concentration in made normal breathing difficult for them. The air between 2.3 and 11 .8 percent at 20 °C (68 overpowering odor knocked several employees °F). As a liquid, THF is less dense than water, to their knees. and THF vapors are heavier than air. 7 Veolia ES Technical Solutions,L.L.C. Case Study JULY2010 Transportation, handling, and storage tanks, 18-inch "long-bolt" manwayss provided precautions for THF urge the exclusion of emergency venting. The weight of the manway atmospheric oxygen. THE guidance also cover kept the opening sealed against the gasket. suggests that reducing water content from THF When pressure developed to lift the cover, the or THE mixtures can leave behind high-boiling bolts allowed the cover to lift at least 1.5 inches. inhibitors and concentrated peroxides, which Both of these relief devices vented directly to increase the possibility of violent explosions. the atmosphere. Many incidents associated with the distillations of peroxidizable materials occur when peroxides All relief valves and rupture disks for pressure become concentrated in distillation residue. vessels relieved directly to the atmosphere. Units However, dilution, frequent peroxide testing, 3 and 4 rupture disks were oriented upward and nitrogen flushing reduce the hazards.' toward the north while the relief valves vented to the east or the north. Tanks and vessels that Vcolia procedures for THF recovery in Unit 4 suffered the most severe damage were located included safeguards to prevent peroxide near the D-14 tank that served as the source of formation such as purging with nitrogen, testing feed to Unit 3. The unit operator blew nitrogen for peroxides every two hours, and adding into this tank just prior to the release. inhibitor as needed. Pure processed THF was stored in a clean tank and could be isolated with valves from the vapor balance line. Under normal operations, the water concentration in Unit 3 could not drop below the azeotrope of 5.3 percent water. Given that the THE was not concentrated beyond the azeotrope during this distillation phase, precautions for peroxide formation were not included in the Unit 3 operating procedure. 3.3 Relief Systems The U.S. Chemical Safety Board (CSB) concluded that uncontrolled venting allowed vapors to accumulate to explosive concentrations outside process equipment. Relief valves and rupture disks protected equipment in Units 1, 3, and 4 and relieved to the atmosphere. A two-inch pressure/vacuum vent relief device provided protection for "normal breathing" when pressure exceeded 0.5 psig or vacuum exceeded 1.55 mmHg for each tank in the dirty and clean tank farms. This device relieved pressure whenever an unbalanced transfer occurred or brought in ambient air to avoid tank collapse under negative pressure. On the dirty BASF. "Tetrahydrofuran(THF)Storage and Handling,"BASF Corporation Chemicals 8 A manway is a large opening at the top of the tank Division, 1998. to allow access. 8 Veolia ES Technical Solutions, L.L.C. Case Study JULY2010 4.0 Consequences south of the suspected source of the release (Figure 2). The Veolia facility has a water storage tank 4 . 1 Onsite Damage intended for use during a fire, which normally contains about 500,000 gallons of water. Rendered inoperative due to ruptured pipes, the Most of the buildings on the site were system failed to suppress the fires constructed of steel frames with metal siding. Overpressure damage to these buildings was '` 'et s extensive, most notably to the decant building, , .-4. located about 75 feet due east of the likely i source of the release. Overpressure forces hit the steel frames on the western side of this building 4 It 'twith such force that their anchoring tore loose Ad4 from the foundation and deflected to the east. Ns i it" "`' T t 1 The explosion and fire damaged all buildings f r and operating units at the site. These areas -� ' '� ett included the administration, drum storage, r.% , 5p�e decant storage, maintenance, and non-hazardous _ 4.... biliii-ap -s , , waste processing buildings, and Units 1 , 3 and 4, A where several dirty tanks were destroyed. The tops of two stainless steel clean tanks also blew Figure 4. Boiler and locker room damage off during the incident. Solvent mixtures spilled from the damaged tanks 4.2 Community Damage and pooled under the dirty tanks. Tank legs in the area immediately east of Unit 3 sagged from The West Carrollton Code Enforcement Officer the intense heat generated by the pool fire that and company records estimate that about 20 erupted after the flammable vapor ignited. residences sustained damage from the explosion. Several tanks appear to have toppled due to the Residents reported broken windows, bent garage intense heat. When falling over they released doors, and chimney detachment. The Code material that fueled a pool fire, which extended Enforcement Officer condemned the garage of the burn time of the fire. one residence. About five neighboring businesses also sustained damage. One local The lab/operations building, which is likely the business less than a quarter-mile away suffered point of origin for the initial ignition of extensive damage, including cracked masonry flammable vapor, was also severely damaged. block walls, broken windows, cracked walls, The interior of the structure displayed minimal misaligned doors, broken ceiling light fixtures, fire damage based on post-incident inspection; foundation shift, bent steel framing, and fallen however, the masonry block, drywall, and doors ductwork. Some offices displayed damage, in the boiler room deflected in an outward suggesting workers may have been injured had direction from the center of the room (Figure 4). they been present at the time of the explosion. Walls throughout the structure were similarly preliminary estimates, including lost production, oriented outward, including most of the exterior property damage, and business disruption, place south wall of the lab/operations building. Roof total costs at about $27 million. panels above the boiler area blew upward. The north side of the building, directly facing the operating plant, remained intact with the exception of the northeast corner, which was due 9 Veolia ES Technical Solutions, L.L.C. Case Study JULY2010 _� z4• r , -! - illir . JT: _ sr 71-r rilliMMIIIIIIell—n ::: I ASIMMIPoriMirrsi.. :_ .d a xh. I; • Figure 6. Neighboring business office damage Figure 5. Residential damage 5.0 Emergency Response Other responding agencies included • U.S. EPA The WCFD dispatch center received the first • Ohio State EPA 9-1 - 1 calls at 12:07 a.m. on Monday, May 4, • Ohio State Fire Marshal 2009. Engine and truck companies from the • Occupational Safety and Health WCFD were the first to respond. Upon arrival, Administration (OSHA) WCFD officers immediately activated the • U.S. Department of Homeland Security National Incident Command System (NIMS) • Department of Power and Light and assigned roles and responsibilities to • Vectren (gas supplier) manage the incident. All responding • Jefferson Regional Water jurisdictions were conversant and compliant with NIMS, and all facets of the response were Due to environmental concerns, responders conducted through a multi jurisdictional Unified allowed the fires on the Veolia property to burn Command Structure with no reported logistical, without applying water because of the proximity jurisdictional, or communication issues. of the facility to a nearby creek and the high area water table. Firefighters applied foam at about Shortly after their arrival, West Carrollton 10:00 a.m. the next day to extinguish the responders directed a request to the Montgomery remaining fires in the dirty tank farm. County Sheriff's Office Foam Bank9 to help extinguish the fire in the dirty tank area. Based The EPA, notified by the National Response on air sampling and observations, responders did Center, deployed a trailer to sample the air not issue a shelter-in-place during the response around the perimeter of the plant, and found no to this incident. hazardous concentrations of toxins. Mutual aid response to the incident included: • Miami Township Fire Department • Moraine Fire Department • Miamisburg Fire Department • Dayton Regional Hazardous Material (HazMat) trailer and foam truck 9 A foam bank is a storage system that maintains a supply of fire-fighting foam intended for use by a network of firefighting agencies. 10 Ohio State Fire Marshal's Office report. 10 Veolia ES Technical Solutions, L.L.C. Case Study JULY20[0 6.0 OSHA PSM Standard 7.0 Findings In a post-incident inspection, OSHA issued 7.1 Veolia citations for numerous violations of the Process Safety Management (PSM)" Standard. The • The vent devices were not designed to OSHA PSM Standard (29 CFR 1910.119) contain or control hazardous and/or toxic requires employers to prevent or minimize the vapor. consequences of catastrophic release of highly hazardous chemicals as well as flammable • Two natural gas-fired boilers were in service liquids and gases. Hexane and acetone are listed in the lab/operations building at the time of chemicals, and Unit 4 processed more than the the incident and most likely provided the threshold quantity so the PSM standard applied. ignition source. The citations alleged that the company failed to • The lab/operations building, which housed conduct compliance audits every three years to the source of the ignition, was located about ensure that policies and procedures were in place 30 feet south of the operating plant and for the handling of flammable liquids. They also served as a mixed-use structure, which was cited worker training deficiencies, inadequate occupied primarily by non-essential testing and inspections of piping and processes, personnel throughout the day shift. a lack of written standards for operating procedures, maintaining mechanical integrity of • The operating plant had an electrical equipment, and other items involving process classification of Class 1, Division 112 and safety. was compliant with electrical code requirements. However, the lab/operations building was not classified under the National Electrical Code(NFPA 70). • No record existed of a process hazard analysis (PHA) to evaluate the siting of the lab/operations building so close to the operating units. • The two most seriously injured workers were in the lab/operations building at the time of incident. While one worker was attempting to mitigate the vapor release in the plant, the second was donning personal protective equipment (PPE) to assist in the effort. Process Safety Management is a regulation promulgated by the U.S Occupational Safety and Health Administration(OSHA). A process is any activity or combination of activities including any use,storage,manufacturing,handling or the on-site 12 NFPA 70,National Fire Protection Association movement of Highly Hazardous Chemicals National Electric Code designation for the location (HHCs)as defined by OSHA and the and necessary protection of electrical equipment in Environmental Protection Agency. areas where flammables are likely to exist. 11 Veolia ES Technical Solutions, L.L.C. Case Study JULY 2010 ir - --_:-___n__—�' _t; : =' a_ i< possibility and effects of fire and other similar risks. NFPA also provides research, training, and . * 'l ` ,• education and has a membership of over 75,000 `tr; ittneN744t. individuals around the world. �' �� 4'44 NFPA codes and standards are widely adopted �,..,�„�- because they are developed using an open, ^ `:' `- � consensus-based process, in accordance with �l ` c - American National Standards Institute standard development process. Volunteer committee members, with a wide range of professional A \ lk. ;_ expertise develop and review all NFPA codes - and standards. Figure 7. Roof and north wall of lab/operations building and boiler room Currently, there are no industry standards available to TSDF owners, permitting agencies, and local fire officials to establish safety 8 .0 Analysis requirements addressing fire and similar risks. While the NFPA does publish occupancy standards for many industrial facility types (e.g., 8. 1 Overpressure Event NFPA 820, Standard for Fire Protection in Wastewater Treatment and Collection Facilities), there is no standard specific to The CSB was unable to determine conclusively TSDFs. the cause of the overpressure event due to the extensive damage in the process area. Based on NFPA 30, Combustible Liquids Code, applies to employee observations and the characteristics of the storage, handling, and use of flammable and the materials being processed, two possible combustible liquids. As defined by NFPA scenarios could have resulted in a release of Section 3.3.6. 1 , Veolia considered the flammable vapor during the nitrogen blowback lab/operations structure an "important building." process: An important building is an occupied structure where egress within two minutes cannot be • Accumulated THE residue containing reasonably expected, or process control peroxides suddenly became active when buildings that require skilled personnel for the exposed to oxygen through the vacuum orderly shutdown of important or hazardous breaker or long-bolt manway. processes. 13 • The line to the dirty tank was inadvertently • Once the unit operator discovered the mis-manifolded prior to the nitrogen release, he began efforts to mitigate the leak blowback, resulting in the pressurization of by approaching shut-off valves located in a nearby dirty tank containing unprocessed, the plant, but could not because of the flammable, or peroxide-containing liquid. overpowering odor of the released material. If the lab/operations building had a centralized shutdown capability and was 8 .2 NFPA located farther away from the operating plant, the unit operator would have been The National Fire Protection Association (NFPA) is an international, nonprofit organization that develops, publishes, and disseminates more than 300 consensus codes and standards intended to minimize the 13 NFPA 30, Flammable and Combustible Liquids Code, Annex A. 12 Veolia ES Technical Solutions, L.L.C. Case Study JULY 2010 able to conduct a safe and orderly shutdown of the plant. NFPA 30, Section 22.4.1.1, guidance for control • Potential for a vapor cloud explosion(VCE) room location, allows for siting as close as 10 is low due to the inherent properties of Class feet to an operating unit processing "stable 1B liquids under storage and release combustible liquids." conditions (lack of confinement, congestion, and release of material under low pressure). • While Veolia appeared to be compliant with NFPA guidance for stable combustible However,at the West Carrollton facility, liquids using Class 1, Division I guidance considerable congestion and for the operating units, the location of the confinement was created by tanks, electrically unclassified lab/operations pumps, and related equipment. building less than 30 feet away provided • The material being released has no potential multiple potential ignition sources for chemical reactions or for condensed- (including three-fired boilers) for any phase explosions. released material. - However, the materials processed at the West Carrollton facility sometimes had 8.3 Center for Chemical Process the potential for chemical reaction. Safety (CCPS) • In addressing the fact that the potential for explosions cannot be entirely eliminated, a The Center for Chemical Process Safety reliance on alarms and operating procedures (CCPS)is a division/directorate of the American along with procedures to minimize potential Institute of Chemical Engineers, which is a 501 ignition sources was considered sufficient. (c)(3) not for profit educational organization. — However, the electrically unclassified The organization identifies and addresses lab/operations building was close process safety needs within the chemical, enough to the plant to provide the initial pharmaceutical, and petroleum industries source of ignition for the incident. through the development of best practice guidelines to prevent or mitigate catastrophic chemical releases. The CCPS publication, "Guidelines for Evaluating Process Plant Buildings for External Explosions and Fires," provides guidance for siting buildings in areas processing Class 1B liquids. All criteria listed in an example for Class IB liquids would have been met by Veolia under the summary statement that "a long and successful operating history exists to support the low explosion potential of NFPA Class IB flammable liquids when handled under the conditions indicated.'" These criteria state that explosions are extremely unlikely because: 14 Center for Chemical Process Safety,Evaluating Process Plant Buildings for External Explosions and Fires,New York, 1996. 13 Veolia ES Technical Solutions, L.L.C. Case Study JULY 2010 9.3 Center for Chemical Process Safety (CCPS) 9.0 Recommendations 2009-10-I-OH-R5 9.1 Veolia ES Technical Revise control room siting guidelines to reflect Solutions the diversity of characteristics that Class 1B flammable liquids can exhibit(e.g.,heavy vapor, and plant areas that provide congestion and 2009-10-1-OH-R1 confinement). During the rebuild of the plant, revise policy to 9.4 Environmental Technology restrict occupancy of non-essential personnel in buildings in close proximity to operating plants. Council 2009-10-1-OH-R2 2009-10-1-OH-R6 (Supersedes 200701.1-NC.R2) During the rebuild, design and install a closed relief system and develop a policy for safe Petition the National Fire Protection venting(e.g., use of a flare) for relief systems to Association, following the guidelines of their the atmosphere. "Codes and Standards Development Process" (www.nfpa.org), to develop an occupancy 2009-10-I-OH-R3 standard specific to hazardous waste treatment, storage, and disposal facilities. The purpose of Conduct a process hazard analysis on all OSHA the standard would be to prescribe technical Process Safety Management covered processes requirements for the safety to life and property to ensure all buildings and structures at the West from fire, explosion, and release; and to Carrollton facility are located and designed in minimize the resulting damage from a fire, accordance with electrical classification and explosion, and release. At a minimum, but not spacing as defined in NFPA 70. limited to,the standard should address: • Hazard Identification 9.2 NFPA • Chemical Fire and Release Protection and Prevention 2009-10-I-OH-R4 • Facility and Systems Design • Employee Training and Procedures • Inspection and Maintenance Revise NFPA 30, Chapter 17, to include a section requiring a written engineering analysis 2009-10-I-OH-R7 to determine the safe separation distance for (Supersedes 2007.01•I•NC•R3) occupied buildings, control rooms, and operating Develop and issue standardized guidance for the areas. The analysis must be acceptable to the authority having jurisdiction, processing, handling and storage of hazardous waste to reduce the likelihood of fires, explosions, and releases at hazardous waste treatment storage and disposal facilities. Include the incident findings, consequences, conclusions, and recommendations from the CSB investigations of the Environmental Quality facility and the Veolia ES Technical Solutions. 14 Veolia ES Technical Solutions, L.L.C. Case Study JULY2010 The U.S. Chemical Safety and Hazard Investigation Board (CSB) is an independent Federal agency whose mission is to ensure the safety of workers, the public, and the environment by investigating and preventing chemical incidents. The CSB is a scientific investigative organization; it is not an enforcement or regulatory body. Established by the Clean Air Act Amendments of 1990, the CSB is responsible for determining the root and contributing causes of accidents, issuing safety recommendations, studying chemical safety issues, and evaluating the effectiveness of other government agencies involved in chemical safety. No part of the conclusions, findings, or recommendations of the CSB relating to any chemical accident may be admitted as evidence or used in any action or suit for damages. See 42 U.S.C. § 7412(r)(6)(G). The CSB makes public its actions and decisions through investigation reports, summary reports, safety bulletins, safety recommendations, case studies, incident digests, special technical publications, and statistical reviews. More information about the CSB is available at www.csb.gov. CS8 publications can be downloaded at www.csb.gov or obtained by contacting: U.S. Chemical Safety and Hazard Investigation Board Office of Congressional, Public, and Board Affairs 2175 K Street NW, Suite 400 Washington, DC 20037-1848 (202)261-7600 CSB Investigation Reports are formal, detailed reports on significant chemical accidents and include key findings, root causes, and safety recommendations. CSB Hazard Investigations arc broader studies of significant chemical hazards. CSB Safety Bulletins are short, general-interest publications that provide new or noteworthy information on preventing chemical accidents. CSB Case Studies are short reports on specific accidents and include a discussion of re/evant prevention practices. All reports may include safety recommendations when appropriate. CSB Investigation Digests are plain-language summaries of Investigation Reports. dle 15 Esther Gesick From: Esther Gesick Sent: Friday, January 20, 2012 8:20 AM To: Wade Cooper Cc: Bruce Barker; Chris Gathman; Trevor Jiricek; Esther Gesick Subject: RE: USR11-002, Anadarko/Kerr-McGee Gathering, LLC - 12/21/2011 BOCC Hearing Good Morning Mr. Cooper, I just wanted to let you know your message was received and will be forwarded to the Board as a matter of communication, as well as added to the file. Please let me know if you need anything further. Thank you, Esther E. Gesick Deputy Clerk to the Board/Office Manager 1150 0 Street'P.O. Box 7581 Greeley, CO 80632 tel: (970)336-7215 X4226 tois Confidentiality Notice:This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged,confidential or otherwise protected from disclosure.If you have received this communication in error,please immediately notify sender by return e-mail and destroy the communication.Any disclosure,copying,distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Wade Cooper [mailto:forwecooper@gmail.com] Sent: Thursday, January 19, 2012 10:20 PM To: Esther Gesick Cc: Bruce Barker; Chris Gathman; Trevor Jiricek Subject: Re: USR11-002, Anadarko/Kerr-McGee Gathering, LLC- 12/21/2011 BOCC Hearing Esther, Sony for the misinterpretation of the Weld County Code. I am just extremely upset with the actions of the Board because they have simply dismissed the public hearing testimonies of residents surrounding the proposed expansion and, in my opinion, they have essentially lied in their resolution when they state that the proposed expansion has adequate provisions to protect the health, safety and welfare of the surrounding inhabitants and is compatible with the surrounding community. With their approval of the proposed expansion, they have in essence further eroded the property values and quality of life for the surrounding inhabitants and properties. Where is the accountability for their dishonesty and not adhering to their own policies and rules? It is clear that they do not understand the hazards associated with high hazard facilities which fall under EPA's Risk Management Program standards (40 CFR Part 68) and OSHA's Process Safety Management standard (29 CFR 1910.119). It is actions such as this that make residents lose all confidence in the governmental bodies that are suppose to protect the welfare and safety of the public. Respectfully submitted, Wade E. Cooper PE, CSP On Thu, Jan 19, 2012 at 12:11 PM, Esther Gesick < gesick@co.weld.co.us> wrote: •�u /C.a�iie-i.,,4) t doica-cot{ /-a5- 20/z PL' 93 Mr. Cooper, The sections you refer to (Sec. 23-6-10 and 23-6-20) are for the purpose of appealing "decisions concerning zoning issues made by any official employed by the Board of County Commissioners in the administration or enforcement of this Chapter." This is the process you would use in instances where the public wishes to appeal the administrative decision of a Department Director who is appointed by the Board of Commissioners to administer the policies within the Weld County Code. Please note the emphasis in bold. Again, I must maintain that if you wish to appeal the decision of the Board of Commissioners,you must file with the District Court no later than January 23, 2012, as previously described. I have copied the County Attorney on this message if you wish to pursue the matter with him for further clarification. Thank you, Esther E. Gesick Deputy Clerk to the Board/Office Manager 1150 O Street P.O. Box 758'Greeley, CO 80632 tel: 1970)336-7215 X4226 c Confidentiality Notice:This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged,confidential or otherwise protected from disclosure.If you have received this communication in error,please immediately notify sender by return e-mail and destroy the communication.Any disclosure,copying,distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Wade Cooper [mailto:forwec000er@omail.com] Sent: Thursday, January 19, 2012 11:55 AM To: Esther Gesick Subject: Re: FW: USR11-0021 Dear Esther, Thank you for your response. However, Articles 23-6-10 and 23-6-20 of the Weld County Code specifically identify the process for appeals of decisions by the Board of Commissioners performed under Chapter 23, which is the Chapter involved in the decision of USR11-0021. Thus, I am resubmitting my previous email dated January 13, 2012 (shown below)with this email under the appeal application procedures of Article 23-6- 20 of the Weld County Code. 2 Below are the appeal application procedure requirements of 23-6-20 with my appeal responses for the Board's decision of Dec. 21, 2011 to approve USRl1-0021: 1. A citation of the section of this Chapter which is the subject to the disagreement. RESPONSE: This appeal is being made under disagreement with the following: A. That the proposed expansion conforms to Section 23-2-230B3- i.e., it is compatible with the surrounding land uses. B. That the proposed expansion conforms to Section 23-2-230B7- i.e., it contains adequate provisions to protect the health, safety and welfare of the surrounding inhabitants. 2. A written description of the grounds for the APPEAL; and the reasons held by the appellant for the favored interpretation. RESPONSE: The grounds and reasons for the appeal are partially presented in the email dated January 13, 2012. Expansion of the facility would increase the maximum onsite quantities of flammable gas/liquid/vapors above the threshold quantities of 10,000 pounds such that the site is not exempt from the EPA's Risk Management Program (RMP) standards (40 CFR Part 68) and OSHA's Process Safety Management (PSM) standard(29 CFR 1910.119). These standards were developed to reduce the safety and health hazards for onsite employees and surrounding inhabitants, but they do not alleviate these hazards, as evidenced by EPA RMP requirements to develop a local emergency evacuation plan. These sites are characterized as process safety facilities which can result in explosive overpressures exceeding current building code design pressures. Subjecting the surrounding inhabitants (currently at least 10 residences within 3/4 mile of the property) to these hazards does not adequately protect the health, safety and welfare of the surrounding inhabitants, and its expansion is therefore incompatible with the surrounding land uses. There is also an additional 12 lots within 3/4 mile of the facility which are slated for residential structures. The expansion will affect the value of these lots and subject these future inhabitants to these hazards. 3. Any other information determined to be necessary by the Board of Adjustment that will aid the Board of Adjustment in making a decision which will not impair the intent and purpose . RESPONSE: Please send me an email with any additional information requirements. Should your office have any questions or need additional information concerning this, please email me as soon as possible. Also please let me know whether this appeal is acceptable and if not, please provide specifical reference information as to why it is not acceptable. Thanks, Wade E. Cooper PE, CSP 3225 County Rd 19 Fort Lupton, CO 80621 3 On Mon, Jan 16, 2012 at 9:20 AM, Esther Gesick <egesickna,co.weld.co.us>wrote: Mr. Cooper, I previously provided correspondence to Pam Cooper and Sherry Been on December 28, 2011, regarding this matter(see attached e-mail titled "Appeal"); however, based on your message below, please allow me to clarify a few items. First, any party may obtain private legal counsel and appeal the decision of the Board of County Commissioners; however,the appeal is made to District Court; not the Board of Adjustment, and must be done within 30 days of the public decision by the Board. Second, I intend to finalize the minutes and Resolution from the hearing this week, if possible; however, filing of an appeal is not contingent upon completion of my typed summary, so do not let that delay your submittal. Third, I understand you are out of town until February 1st; however,the official case file has been available for public inspection since public notice was sent in October, 2011, and the deadline for filing an appeal is January 23, 2012. Any member of the public may come to our office and review the file on your behalf and copies cost$0.25 per page, or I can provide a digital copy of the entire file via e-mail, at a cost of$0.10 per page= $22.50. Lastly, this e-mail and the attachments you provided will also be added to the file and circulated for Commissioner review as a matter of correspondence on the 1/18/12 Agenda. Regards, Esther E. Gesick Deputy Clerk to the Board/Office Manager 1150 O Street/P.O. Box 7581 Greeley, CO 80632 tel: (970)336-7215 X4226 Confidentiality Notice:This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged,confidential or otherwise protected from disclosure.If you have received this communication in error,please immediately notify sender by return e-mail and destroy the communication.Any disclosure,copying,distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. 4 From: Wade Cooper [mailto:forwec000er@gmail.com] Sent: Friday, January 13, 2012 4:09 PM To: Esther Gesick Subject: USR11-0021 Dear Esther, I am writing to you because it is my understanding that the Weld County Code (Article 23) allows an appeal of the Board of Commissioner's decision to the Board of Adjustment within 30 days of their decision. In accordance with this appeal procedure, I am appealing the Board of Commissioner's approval of USR11-0021 to the Board of Adjustment. I have been unable to locate on the Weld County website any information on USR11-0021 since it was apparently approved on Dec. 21, 2011. To properly and completely appeal the Board of Commissioners approval of USR11-0021, Frederick Compressor Station expansion, I would like to review the entire official record for the case. After being able to review the complete official record, I will be more informed to fully address my appeal to the Board of Adjustment. I am currently out of state until Feb. 1st, but would like to arrange a review of its official record sometime after I return. Please let me know if your office can accomodate this request. I am currently appealing the Board of Commissioners approval of USR11-0021 to the Board of Adjustment based on its lack of conformance with Article 23-2-260.A.7. as presented below: 7. A statement which explains that there is adequate provision for the protection of the health, safety and welfare of the inhabitants of the NEIGHBORHOOD and the COUNTY. This nonconformance is predicated on the site expansion resulting in large quantities (greater than 10,000 pounds) of flammable gases/vapors/liquids on site such that the site would no longer be exempt from both OSHA's Process Safety Management standard(29 CFR 1910.119) and the EPA's Risk Management Program standard(40 CFR Part 68). These two standards are recognized in process safety as hazardous facilities which pose additional safety and health risks to surrounding communities. The standards were developed to help mitigate the fire and explosion hazards associated with such large quantities of highly hazardous chemicals, but they alone do not prevent such catastrophic events from occurring. The fact that the large quantities of flammable gases/vapors/liquids pose additional safety and health risks (including hydrogen sulfide gas and overpressures due to explosions) to surrounding inhabitants demonstrates that the proposed expansion will adversely affect the health, safety and welfare of the surrounding inhabitants. Below are presented numerous flammable gases/vapor/liquid incidents investigated by the Chemical Safety Board (CSB) in recent years. They are by no means conclusive of all incidents, but details some of the more catastrophic incidents investigated by the CSB. Please consider this information. 5 1. A propane tank explosion at Leprino Foods in Greeley CO. on Friday, Dec. 23, 2011 (just 2 days after our public hearing where I warned the Board of Commissioners about the fire/explosion hazard of the proposed expansion). No injuries, but it shook buildings and possibly damaged some in the surrounding community. The whole article is not available without a subscription. http://www.greeleytribune.com/article/201 1 1 223/NE W S/712239989/1078 2. Conagra Slim Jim plant http://www.csb.gov/newsroom/detail.asnx?nid=300&SID=0&pr=1&F All=y 3. Board investigators said they have identified a number of similar gas purging accidents in recent years, including an explosion at a Michigan power plant in 1999 that killed 6 and caused $1 billion in property damage and an explosion in 2008 at a San Diego hotel that injured 14. 4. NDK America, Rockford IL -Note a member of the public was killed by debris which was thrown over 300 yards. http://www.csb.gov/newsroom/detail.aspx?nid=297&SID=0&pg=1&F All=y 5. Kleen Energy Plant, Middletown, CT. Feb. 7, 2010. Six killed, 50 injured. Purging pipelines with natural gas See attachment. 6. Silver Eagle Refinery, Woods Cross, UT , 11/17/09- hydrogen gas explosion damaged over 100 off-site homes. 6 http://www.csb.gov/newsroom/detail.aspx?nid=296&SID=0&na=1&F All=y 7. Safety message by CSB about how pressure vessels without proper safety safeguards can be catastrophic. Urges jurisdictions throughout the US to adopt the ASME Pressure Vessel Code. Colorado does not exercise enforcement of the code. The compressor receivers, slug catchers, and separators as well as some storage tanks are pressure vessels (i.e., operate at pressures above 15 psig). http://www.csb.gov/newsroom/detail.aspx?nid=293&SID=0&pg=1&F All=v 8. Barton Solvents, Des Moines, IL, Sept 2008, fire and explosion of flammable solvents due to improper bonding and grounding. Similar to what can happen at the storage vessels at the Frederick Compressor Station. http://www.csb.gov/newsroom/detail.aspx?nid=45&SID=0&vg=1&F All=y 9. Valero Refinery, Sunray, TX July 2008. Propane release fire and explosion. http://www.csb.gov/newsroom/detail.aspx?nid=41&SID=0&pg=1&F Investigationld=12 10. Veolia Environmental, Carrollton, OH May 4, 2009, Flammable vapor fire and explosion, damaged 20 offsite buildings. see attachment. 11. Little General Store, Ghent WV, Jan 30, 2007. Propane leak fire and explosion. Leveled the store, damaged nearby vehicles, Killed 4, injured 6. See attachment. These are just some of the many major incidents demonstrating that the large quantities of flammable gases, vapors, and liquids, such as at the proposed compressor station, can have catastrophic damages, even to offsite residences/buildings. 7 Wade E. Cooper, PE, CSP 3225 County Rd 19 Fort Lupton, CO 80621 Forwarded message From: Esther Gesick < esick@co.weld.co.us> To: Sherry Been<wereafrog@yahoo.com> Cc: Esther Gesick<egesick@co.weld.co.us>, "dreamwriter9@gmail.com" <dreamwriter9@gmail.com>, Bruce Barker <bbarker@co.weld.co.us>, Michelle Martin <mmartin@co.weld.co.us> Date: Mon, 16 Jan 2012 08:34:58 -0700 Subject: RE: appeal Sherry, Please see the attached prior correspondence regarding your questions. As for status on the case, I have completed the regular 9:00 board meeting minutes and documentation, and one of the three land use hearings from the 21st,which just leaves one other case and the case you are interested in, which I will be working on starting today. I will forward a copy of the Resolution and minutes as soon as they are complete. Esther E. Gesick Deputy Clerk to the Board/Office Manager 1150 O Street P.O. Box 7581 Greeley, CO 80632 tel: (970)336-7215 X4226 8 Confidentiality Notice:This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged,confidential or otherwise protected from disclosure.If you have received this communication in error,please immediately notify sender by return e-mail and destroy the communication.Any disclosure,copying,distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Sherry Been [mailto:wereafrogevahoo.com] Sent: Friday, January 13, 2012 8:45 PM To: Esther Gesick Subject: appeal Hi Esther, Several of the residents that live around the approved gas expansion would like to appeal the decision to allow the expansion. Could you please send me information as to whom we appeal to. You had stated that we have 60 days. Is that the case or is it only 30. If you could contact me at 303-902-9262, that would be great. Thank you Sherry Been Forwarded message From: Esther Gesick <egesick@co.weld.co.us> To: Pam Imler-Cooper<dreamwriter9@gmail.com> Cc: Esther Gesick<ggesickAco.weld.co.us> Date: Thu, 29 Dec 2011 10:16:38 -0700 Subject: RE: Appeal of Board of Commissioners decision Pam, I did also receive confirmation from the County Attorney that any party may appeal the Commissioners' decision; however, it must be filed within 30 days from the action date (December 21st.) Esther E. Gesick Deputy Clerk to the Board/Office Manager 9 1150 O Street'P.O. Box 758'Greeley, CO 80632 tel: 1970)336-7215 X4226 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged,confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication.Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Pam Imler-Cooper [mailto:dreamwriter9@gmail.com] Sent: Wednesday, December 28, 2011 4:47 PM To: Esther Gesick Cc: Arlen Siert; Dean Felton; Dolf Veit; Greg Brand; Joe &Lori Harrison; Jolene &Lynn Johns; Pam Imler-Cooper; Pat& April Thorpe; Roray Alguessev; Sherry Been; Steve Ceplius; Wade Subject: Re: Appeal of Board of Commissioners decision Thank you so very much for your attention to our issue, Esther. All of us appreciate the information you've provided. We may not like the Board's decision, but at least we know what steps to take in order to appeal. For that, we thank you very much. Happy New Year, Pam Cooper On Wed, Dec 28, 2011 at 3:22 PM, Esther Gesick <egesick@co.weld.co.us> wrote: Hello Pam, to I'm sending you this message in response to a call I received earlier today from Sherry Been. As I indicated to her on the phone, both the applicant or the public may appeal a decision of the Commissioners to the District Court. The County Attorney indicated the party in opposition to the Board's decision has the right to obtain private legal counsel who may advise them on the appropriate process for contesting the decision. Also, as a follow-up on timing of when I may have the minutes for the 21st completed- I have one more hearing to type from December 7th and have completed the regular business from the 12th and will be moving forward to items from the 14th later this week. Happy New Year! Esther E. Gesick Deputy Clerk to the Board/Office Manager 1150 O StreetIP.O. 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