Lessons Learned from the October 16, 1995 Accident at the Pennzoil Refinery in Rouseville, Pa.

EPA Recommendations

The EPA developed the following recommendations that address the root causes and contributing factors to prevent a recurrence or similar event at this and other facilities:

  • Process safety management systems and process hazards analysis techniques should include waste handling operations to ensure that all chemical and process hazards are identified and controlled and equipment integrity is maintained;

  • Pennzoil and other facilities should examine hot work permit processes and consider development of management systems to ensure that all vapor and ignition sources are identified and controlled;

  • Facilities need to recognize the impact of changing conditions on hot work and other hazardous work tasks. Industry should consider the value of continuous or periodic work permit rechecks and the application of process hazard analysis techniques to ensure greater control over possible changes in routine work situations;

  • Facilities should use hazard assessment techniques to address the hazards associated with vehicular access and location of temporary work trailers in the vicinity of storage vessels; and

  • The potential for catastrophic vessel failure, no matter how remote, should be evaluated along with other likely spill and leak scenarios, to determine the need for secondary containment or other impoundment as a means of preventing impact on other site areas.

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    OCAW Recommendations for Safety System Improvements

    1. The application of the OSHA Process Safety Management (PSM) standard should be clarified and extended to cover storage tanks and associated piping that may contain highly hazardous materials or flammables.

      Storage tanks similar to the ones that exploded are often not considered to be covered by the OSHA PSM standard. The exclusion of many storage tanks from PSM coverage is inappropriate. Insurers of the petrochemical industry report that nearly 50 percent of all mechanical failures resulting in disasters involve storage tank or pipe failures.

    2. OSHA should issue improved regulations for hazardous material and flammable storage tank design, inspection and maintenance.

      Causes of the disaster included unsafe construction design and lack of inspection and maintenance of the tanks. Reliance on American Petroleum Institute and other industry published recommendations is inadequate because many of these guidelines primarily address newly installed equipment. For existing equipment, companies are usually only expected to consider whether or not they should comply with safety guidelines.

    3. The practice of grandfathering substandard equipment used to handle hazardous material and flammables should be discontinued.

      The Pennzoil tanks that exploded were nearly 60 years old and did not meet modern design safety requirements. The general practice of applying design safety guidelines only to newly constructed equipment while using inferior guidelines for existing equipment should be stopped. Workers operating and maintaining older process or storage equipment deserve the same degree of safety protection as workers involved with new equipment.

    4. OSHA should require that each storage tank that may contain hazardous materials or flammables must be individually diked.

      Failure by Pennzoil to individually dike tanks allowed burning liquid to quickly spread over a wide area of the plant, causing extensive damage. OSHAs diking standards need to be strengthened.

    5. OSHA should require that a safe siting analysis be performed prior to trailers being located near equipment that may contain hazardous material or flammables.

      The placement of four contractor trailers in close proximity to the tanks allowed the fire to quickly engulf the trailers, resulting in the deaths of three workers.

    6. OSHA should strengthen requirements that storage tanks that may contain flammable material must be equipped with adequate pressure relief devices and frangible (fail first) roof seams.

      The lack of these basic safety features allowed the tanks to fail at their bottom seams and take off like rockets, releasing all of the flammable contents.

    7. OSHA should require that a safe siting analysis is conducted on storage tanks that may contain hazardous materials or flammables.

      The tanks that exploded were located only 4 feet apart. This allowed the explosion of the first tank to immediately spread to the second tank. This siting analysis should insure that a fire in one tank will not spread to other tanks.

    8. Industry should develop improved procedure and training programs that address proper isolation, preparation and testing of work areas for hot work. Training and procedures should address the hazard of increasing ambient air temperature generating flammable vapors. Training should include a review of the Pennzoil accident and other similar major accidents.

      The tank that first exploded was not properly isolated prior to welding being conducted. Numerous openings in the tank allowed flammable vapors to be released. The hazard of increases in ambient air temperature generating increasing amounts of flammable vapor was not recognized in the facility training program or in its welding procedures.

    9. OSHA should require continuous air monitoring for flammables when hot work, such as welding, is permitted near equipment that may contain flammable material. This requirement should apply to storage tanks.

      Air tests at Pennzoil showed that it was safe to weld in the early morning hours. However, conditions are often changing in facilities such as oil refineries. In this case, a change of only 9 degrees in the outside temperature over about 2 1/2 hours generated flammable vapors that ignited. Monitoring the air for flammable vapors once in the morning or periodically is not sufficient. Continuous monitoring for flammables can be easily accomplished using existing testing equipment found in most facilities.

    10. OSHA should require that when feasible, air monitoring for toxics is conducted whenever testing for flammable vapors is performed.

      The material that exploded at Pennzoil was methyl ethyl ketone (MEK). The EPA report ignored the toxic hazard of this material. Many flammable materials exceed their permissible exposure level (PEL) for health protection at concentrations far lower than their lower explosive limit (LEL). The PEL for MEK is 90 times lower than the LEL. The Immediately Dangerous to Life and Health (IDLH) level for MEK is 6 times lower than the LEL. Monitoring for toxic exposure to MEK or other toxic flammables provides advanced warning of danger.

      Many companies believe that workers are protected from toxic exposures because their safety programs do not allow hot work, such as welding, when flammable vapors exceed 10 percent of the LEL. This is a mistake. In the case of MEK, 10 percent of the LEL is still 9 times the PEL. The safe health exposure levels for common flammable materials such as benzene, toluene, xylene, and styrene are even lower than the level set for MEK.

    11. Employers should create procedure and training programs that address the control of each hazardous material that is loaded by vacuum trucks and the specific safe locations and methods for discharging each material.

      The tank that exploded contained a considerable amount of MEK. The tank was not designed to safely store this flammable material. Company procedures did not cover essential elements of the safe operation of vacuum truck loading and unloading.

    12. Mechanical integrity programs must insure that gravel and dirt are not allowed to accumulate around the base of storage tanks, as this can trap moisture and accelerate corrosion.

      The build-up of gravel and dirt around the bottom of the tanks that exploded allowed severe corrosion to take place around the bottom seams. These seams failed catastrophically.