Washington D.C., July 11, 2024 - Today, the U.S. Chemical Safety and Hazard Investigation Board (CSB) released a new safety video on its investigation into the fatal release of acetic acid at the LyondellBasell La Porte Complex in La Porte, Texas, on July 27, 2021, that killed two contract workers. Approximately 164,000 pounds of a highly corrosive acetic acid mixture erupted from equipment when three contract workers inadvertently removed critical components of a plug valve. All three workers were sprayed with the acetic acid mixture. Two of the workers died from their injuries.
The CSB's new safety video, called “Designed to Fail: Chemical Release at LyondellBasell,” includes an animation of the events leading to the incident, as well as commentary from CSB Board Member Dr. Sylvia Johnson and CSB Investigator Benjamin Schrader.
The CSB released its final investigation report on the fatal LyondellBasell incident on May 25, 2023. The CSB’s investigation found that the incident occurred when three contractors from Turn2 Specialties Companies attempted to isolate a pipe section located between a leaking pipe and an acetic acid reactor. To do so, they decided to lock a plug valve in the closed position by removing the valve’s actuator. However, LyondellBasell did not have a procedure detailing how to remove the actuator, and neither LyondellBasell nor Turn2 trained the Turn2 personnel on how to remove the actuator. Instead, the contractors inadvertently removed pressure-retaining fasteners that were holding the valve cover in place and should not have been removed to uninstall the actuator. The compromised valve failed, and all three Turn2 workers were sprayed by the acetic acid mixture.
When the CBS’s final investigation report was issued, CSB Chairperson Steve Owens had noted that “[t]here have been similar incidents around the country involving plug valves being inadvertently taken apart when removing connected equipment” and urged that action be taken to address this issue.
The safety video addresses the two key safety issues identified in the CSB’s final report that contributed to the incident: (1) valve design to prevent human error and (2) providing workers with conditions, procedures, and training to safely conduct work. The video also highlights safety recommendations made by the CSB to the American Society of Mechanical Engineers, the American Petroleum Institute, and LyondellBasell.
In the video Board Member Johnson states: “As this tragic incident has shown us, even a simple task can turn deadly if it is not properly performed. It is time to improve the design of plug valves and take other protective actions, such as ensuring that clear markings are visible on all existing plug valve pressure-retaining components, and workers are properly trained before conducting maintenance. Vital steps like these can go a long way in injury prevention and help save lives.”
The CSB is an independent federal agency charged with investigating incidents and hazards that result, or may result, in the catastrophic release of extremely hazardous substances. The agency’s core mission activities include conducting incident investigations; formulating preventive or mitigative recommendations based on investigation findings and advocating for their implementation; issuing reports containing the findings, conclusions, and recommendations arising from incident investigations; and conducting studies on chemical hazards.
The agency's board members are appointed by the president subject to Senate confirmation. The Board does not issue citations or fines but makes safety recommendations to companies, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA.
Please visit our website, www.csb.gov. For more information, contact Communications Manager Hillary Cohen at [email protected].