Propane Tank Flare off in Topeka; Cause and Effect Chart

(Simplified version) 12-2-02

CB = caused by
Use of CB Portable flare Driver statement Potential Fire CB & Explosion Manager statement 500 gallons in CB Customer tank Truck flow meter Unable to contain Liquid propane Driver statement Deemed safest method CB Unable to CB Disconnect Truck From Customer tank Driver statement CB Risk Analysis recommendation Risk Matrix results Customer Tank size Observation Routine fill Order log CB Corrosion CB Metallurgist Obs

Unable to stop CB Propane liquid back-flow Driver statement

Stop

Primary Effect

Did not desire Uncontrolled Stop release -Driver statement -Following Co. Policy

Stop Stop
Carbon steel spring

Large volume Of propane Requiring disposal Driver statement

Stop

EVIDENCE
Spring failure Back-check Valve failure CB

Metallurgist Observation Exposure to elements? CB

Mechanic Observation No Maintenance Maintenance Records CB CB

Mechanic Observation Safety adapter not used (reqd for Acme Valves) Driver statement Acme type CB Filler valve Driver observation Fill nozzle CB In liquid space Tank Drawing

?
CB

?
Acme filler Valves Not common Driver statement

CB

Driver forgot To use Driver statement

Infrequent use CB

CB

Stop

Driver statement

1963 Tank Design Tank Drawing

CB

Tank not upgraded Maintenance Records Acceptable in 69 When installed Engineer statement

Didnt remember CB training Driver statement No signs on tank CB Driver observation

Training CB ? Ineffective?

Stop

Propane Tank Flare off in Topeka

I. Problem Definition What When Where Significance Primary Effect: Date & Time: Relative Timing: Business/Unit Location:

ABC Propane Company GOAL: Prevention, not blame.

Potential Fire & Explosion due to propane flare off in downtown Topeka June 13, 2002 While filling customers 500 gallon propane tank ABC Propane/Topeka Distribution and Service Center Topeka, KS; 45th and Wilson St.

Safety: Potential injury to truck driver and nearby residents; no actual injuries Environmental: Visible smoke, ~100 lb release of unburnt propane Production: (lost profit) $1,500 in missed customer deliveries, negative Total $ $2,000 publicity, $500 in lost propane Costs: $750 in overtime costs for truck and driver, Total $ $9,050 $3,300 emergency response costs, $5,000 fine Total Incident Cost $11,050 this incident Grand $11,050 $ 43,450 in last 6 months Total $ Frequency: 5th occurrence of same type in last 6 months

II. Cause and Effect Summary Statement (Refer to attached Cause and Effect Chart) The potential fire and explosion at the customers location in Topeka was caused by the large volume of propane requiring disposal and use of the portable flare. The large volume of propane was caused by a full 500 gallon customer tank caused by the driver completing a routine fill. The use of the portable flare was caused by the driver being unable to contain the liquid propane, the large volume of propane requiring disposal and it was deemed the safest method for disposal. The driver was unable to contain the liquid propane because he couldnt disconnect the fill hose from the customers tank. It was deemed the safest method because of past risk analyses. He couldnt disconnect the fill hose because he was unable to stop the back-flow of propane from the tank, and he didnt want an uncontrolled release. The flow of liquid propane wouldnt stop because the back check valve failed, the filler valve was an Acme type, the hose end safety adapter wasnt used (required for Acme valves), and the fill nozzle discharge is located in the liquid space. The back check failure was caused by a spring failure and no maintenance. The spring failure was caused by corrosion. The corrosion was caused by a carbon steel spring and the valve may have been exposed to corrosive elements. The safety adapter was not used be because the driver forgot to use it. The driver fogot because of infrequent use of the adapter, he didnt remember his training and there were no signs on the fill nozzle when there should have been. The adapter is used infrequently because there are not many tanks remaining that still use the valve. Both the prescence of an Acme valve and the fill nozzle located in the liquid space are caused by a 1963 tank design. The 1963 tank design was caused by the tank not being upgraded, and this was an acceptable design when the tank was installed. III. Solutions The following are the correction actions/solutions for the cause and effect relationship listed above. Cause No signs on Tank Action 1) Install sign on this tank indicating Acme Valve-use safety adapter, 2) Install signs on all remaining tanks with Acme valves Replace Back Check valve with new valve with Hastelloy C spring. Tie pouch to hose; store safety adapters in pouch Communicate this RCA to all drivers Assigned Becky Cooper Due By 1) June 14 2) July 1 June 14 July 1 June 21

Back Check valve failed & Carbon steel spring in valve Safety Adapter not used Driver Forgot to use adapter

Becky Cooper Roger Wickes Dan Jamison

Investigation Started: June 13, 2002 Investigating Team: John Stevens, Becky Cooper, Dan Jamison, Roger Wickes Comments: If you have any comments or questions please contact John Stevens on 123-456-7890. s:\ABC\Topeka\RCA\Flare off #5 Page 1