Chemical Reactivity Incidents

During facility operation, a chemical reactivity incident or near miss may occur despite all efforts to effectively manage chemical reactivity hazards. An essential element of managing chemical reactivity hazards is to appropriately report and investigate every incident or near miss involving chemical reactivity hazards. By investing the time and effort to determine the root causes and take corrective 

The objective of incident investigation is to prevent recurrence of similar events. This is accomplished by establishing a management system for investigation that ensures  

These goals are listed in the order of importance to a company. Of greatest importance is to get near misses reported so that investigation can be used to learn from the incident. Note that incident investigation techniques are essentially the same whether applied to chemical reactivity hazards or to other hazards. 

By way of definition, a near miss is an unplanned sequence of events that could have caused harm or loss if conditions were different or were allowed to progress, but actually did not. Incidents include both near misses and actual loss events. 

The essential practices for investigating chemical reactivity incidents can be grouped into three categories  

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The purpose of this publication is to contribute to a continued reduction in the number and severity of incidents involving uncontrolled chemical reactions in the workplace. The obj ective of this publication is to convey the essentials of managing chemical reactivity hazards—those elements that are necessary, but not always sufficient, to avoid or mitigate chemical reactivity incidents. Implementing these elements should result in a management system that will, on an ongoing basis ... 

Prevent chemical reactivity incidents by designing, constructing, operating and maintaining the facility in such a way that all chemical reactivity hazards are contained and controlled. 

Many millions of tons of useful products and substances are safely made by chemical reactions each year. Nevertheless, intended reactions can lead to major loss events if inadequately controlled. The following is an example of a chemical reactivity incident in a process with intentional chemistry (EPA 1999a). 

Appendices contain case histories of chemical reactivity incidents, a sample inherently safer process checklist, and the Executive Summary of the CSB hazard investigation report on "Improving Reactive Hazard Management (CSB 2002b). 

Managing chemical reactivity hazards is not a one-time project, review, or audit. It is also not a written program document to put on the shelf and ignore. Managing chemical reactivity hazards is an ongoing effort to protect employees, contractors, customers, the public, environment, and property against the potential consequences of chemical reactivity incidents. 

Tell emergency responders and other potentially affected persons, including industrial and residential neighbors, what to expect and how to respond to a chemical reactivity incident if one occurs at your facility. 

Investigate Chemical Reactivity Incidents Incident Investigation Incident Investigation Monitoring Performance... 

Some of the key factors to consider when designing, operating and maintaining intentional chemistry processes are listed below. These factors can have a major effect on either the likelihood of a chemical reactivity incident or the severity of the incident consequences. 

Investigate Chemical Reactivity Incidents 4.10 Review, Audit, Manage Change, Improve Hazard Management Practices/Program ... 

Line management participates in the investigation of all chemical reactivity incidents and near misses, and makes resources available to implement corrective actions. 

Case histories of chemical reactivity incidents, such as those in Appendix A-l, are useful in getting needed attention and priority for a chemical reactivity hazard management system. Other companies programs, such as the ones shared on the CD-ROM accompanying this publication, can be... 

A chemical reactivity incident does not have to be a violent fire or explosion. In reality, uncontrolled reactions can be slow or start slowly and still result in injury, loss or environmental damage. As useful as they may be for... 

When previous chemical reactivity incidents have been examined, particularly where established instructions were not followed, it is often found that facility personnel did not know that violating the procedure could lead to an uncontrolled reaction. Knowledge of the chemical reaction hazards would make procedural violations less likely. 

Implementing a recommendation must go beyond an equipment, process or procedural change. What was learned about an incident or near miss and its causes, as well as the changes made to prevent recurrence, needs to be effectively communicated to employees. As a result, they will have a greater understanding to better identify future near misses and the factors that could lead to a chemical reactivity incident at their facility. This will also encourage employees to report other near misses. 

Encourage wider use of emergency response preplanning for chemical reactivity incidents integrate consequence analyses for chemical reaction systems with emergency response scenarios... 

Part of learning everything possible from previous incidents (so as not to repeat them ) is to study case histories that have been made available. For chemical reactivity incidents, many case histories have been published by the sources listed below. Also given in this appendix are extended abstracts of several recent incidents that are particularly instructive. 

Barton and Rogers (1997) gives a compilation of 100 brief case histories related to chemical reactivity incidents. These incidents are grouped according to the following summary causes ... 

The U.S. Chemical Safety and Hazard Investigation Board (CSB) has conducted detailed investigations into a few chemical reactivity incidents. Case studies and full investigation reports are available from the CSB (Washington, DC) or its website (www.chemsafety.gov). Extracts from three CSB publications (1998,2002a, 2002c) are given here. 

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