Management of Organizational

Change: A CSB Perspective

Rick Engler Process Safety Conference

CSB Board Member May 17, 2017 - Dordrecht
Driving Chemical Safety Change through Independent
Investigations to Protect People and the Environment

www.csb.gov
 What is the CSB?
• The CSB is an independent, non-regulatory U.S.
Federal agency charged with investigating chemical
accidents
– ~40 professional staff; $11 million annual budget
– Board members are appointed to 5-year terms by the
President and confirmed by the Senate.
• CSB conducts root cause investigations of chemical
accidents at fixed industrial facilities.
• The agency does not issue fines or citations.
• Primary policy levers are outreach and safety
recommendations.

www.csb.gov
 Types of Incidents That We Investigate
Jurisdiction: Release of hazardous substance into the ambient
air from a fixed facility (with consequences)

• Incidents in chemical plants, oil

refineries and facilities using
chemicals
• Toxic gas releases
• Explosions
• Other fatalities, e.g., confined
space, hot work
• Major environmental releases

www.csb.gov
Deployment Criteria
• Deaths or injuries onsite or
offsite
• Substantial property loss
• Offsite public or
environmental impact SOURCE: St. Louis Fire Department

• Broad national significance

• Issue of interest
• Available resources

SOURCE: KMOV via AP

www.csb.gov
 What Investigators Do
• Respond quickly to scene
• Gather physical evidence
• Interview people
• Test equipment
• Comb through documentary evidence
• Draft reports with proposed recommendations for Board approval

www.csb.gov
 Current Investigations & Deployments

Investigation Location Incident Date

DuPont Toxic Chemical La Porte, TX November 15, 2014

Release

Delaware City Refining Delaware City, DE November 29, 2015

Company

Enterprise Products Partners Pascagoula, MS June 27, 2016

Fire and Explosion

Sunoco Logistics Partners Nederland, TX August 12, 2016

Flash Fire

MGPI Products, Inc., Toxic Atchison, KS October 21, 2016

Chemical Release

ExxonMobil Refinery Chemical Baton Rouge, FL November, 22, 2016

Release and Fire

Packaging Corporation of DeRidder, LA February 8, 2017

America Hot Work Explosion

Loy-Lange Box Company St. Louis, MO April 3, 2017

Report to be released soon

www.csb.gov
 Recently Closed Investigations

Investigation Location Incident Date

Williams Olefins Plant Fire and Explosion Geismar, LA June 13, 2013
Freedom Industries Chemical Release Charleston, WV January 9, 2014
ExxonMobil Refinery Explosion Torrance, CA February 18, 2015
Airgas (Air Liquide) Nitrous Oxide Cantonment, FL August 28, 2016
Explosion

www.csb.gov
 Drivers of Critical Chemical Safety
Change (‘Critical Drivers List’)
The CDL is a CSB Program to:
• Identify the most important chemical safety
improvement goals of the CSB
• Pursue implementation of changes most likely to
advance chemical safety
• Focus special advocacy efforts by Board Members and
staff
• Inform deployment decisions and allocation of resources

www.csb.gov
Current Critical Drivers List

www.csb.gov
Significant Historical Process Safety Events

Phillips 66 (1989)
23 Dead; 314 Injured;
$716 MM in damage

Union Carbide, Bhopal (1984)

Thousands dead; tens of thousands injured
Arco Chemical (1990)
17 Dead; 5 Injured;
AP Photo/Sondeep Shankar $36 MM in damage
www.healthandsafetyatwork.com
www.gendisasters.com
www.csb.gov
Clean Air Act Amendments of 1990
Created CSB

Mandated that EPA promulgate a

rule for chemical accident prevention
→ Risk Management Plan rule (RMP)

Mandated that OSHA promulgate a rule

on chemical process safety
→ Process Safety Management standard
(PSM)
www.csb.gov
 Process Safety Management

• A standard issued in 1992 in response to

serious chemical industry accidents
• Main goal is to prevent or minimize
employee exposure to the hazards of
uncontrolled releases of hazardous
chemicals
• Triggered by exceedance of threshold
quantities of “highly hazardous
substances”
www.csb.gov
 Key Elements of PSM Standard
• Process Safety • Management of Change
Information • Incident Investigation
• Process Hazard Analysis • Compliance Audits
• Operating Procedures • Trade Secrets
• Training • Employee Participation
• Contractors • Pre-startup Safety
• Mechanical Integrity Review
• Hot Work • Emergency Planning and
Response
www.csb.gov
 Management of Change (MOC)
MOC requires employers to establish and
implement written procedures to manage
changes to process chemicals, technology,
equipment and procedures; and changes to
facilities that affect a covered process.

Inadequate MOC has led to serious

incidents.

www.csb.gov
MOC Includes Organizational Change
“Some organizational changes such as
changes resulting from mergers,
acquisitions, reorganizations, staffing
changes, or budget revisions may affect
PSM at the plant level and would therefore
trigger a PSM MOC procedure.”
OSHA Memorandum for Regional Administrators on
Management of Organizational Change, March 31, 2009

www.csb.gov
Past CSB Investigations of Relevance
• BP America Refinery Explosion (Texas City
TX, 2005)
• Formosa Vinyl Chloride Monomer
Explosion (Iliopolis IL, 2004)
• Tesoro Refinery Process Safety Culture
Case Study (Martinez CA, 2014)

www.csb.gov
BP America Refinery Explosion (2005)

www.csb.gov
Formosa Vinyl Chloride Monomer
Explosion (2004)

www.csb.gov
Tesoro Martinez Refinery Sulfuric Acid
Spills (2014)

www.csb.gov
Tesoro Martinez Refinery (Martinez, CA)
1997 2010-2014
Explosion and Fire 15 Sulfuric Acid Releases*
(1 dead, 46 injured) (18 injured)
Fire*
Subject of CSB
(4 dead, 1 injured)
Investigation
1999
Valero (2002)

1988
Tosco Corporation (Avon) 1994 2000 2006Tesoro (2002-present)2012

Ultramar Diamond
1976 Shamrock (2000)
2017

Different owner, many of the same managers and operators.

Corrective actions taken after 1999 fire were tracked internally but
major safety culture issues persisted.
www.csb.gov
Safety Culture Assessments at the Martinez
Refinery
Ultramar (April 2001)
• Firm management commitment
to safety
• Safety communication effective
and consistent
Tosco (March 1999)
• “Like night and day”
• Lacked a commitment to safety Tesoro (2013)
• Prioritized economics over safety • Mixed, some long-timers say
• Not good at communicating better than Tosco.
lessons learned • Workers not encouraged to raise
issues.
• “Nobody” wants to work in alky
unit.

1999 2010-2014
1997

Valero

1988
Tosco Corporation (Avon) 1994 2000 2006 Tesoro 2012

Ultramar Diamond
1976 Shamrock
2017
www.csb.gov
 Recent and Current Investigations
Incident Incident Date Transfer Date Consequence
Enterprise Pascagoula June 2016 June 2016 Acquired shortly
Gas Plant Explosion and before incident
Fire
Air Liquide Facility Fatal August 2016 May 2016 Acquired shortly
Explosion before incident
Exxon Mobil Torrance February 2015 September Put up for sale
Refinery Explosion 2014; before incident;
September Sold after incident
2015
DuPont LaPorte Facility November March 2016 Unit shut down;
Toxic Chemical Release 2014 [permanent Division spun off in
closure anticipation of
announced] merger with Dow.

www.csb.gov
Stay in Touch with the CSB

USCSB

@chemsafetyboard

U.S. Chemical
Safety Board
www.csb.gov