CSB Releases Final Report

CSB Releases Final Report into Chemical Release at MGPI Industries; Report Emphasizes Key Safety Lessons to Prevent Future Inadvertent Mixing Incidents – The U.S. Chemical Safety Board released its case study titled “Key Lessons for Preventing Inadvertent Mixing During Chemical Unloading Operations,” which examines a mixture of incompatible materials at the MGPI Processing Plant in Atchison, Kansas on October 21, 2016. The mixture resulted in a chemical release containing chlorine and other compounds that traveled into the community. The CSB’s investigation examines several key issues including the design of chemical transfer equipment, automated and remote shut off systems, and chemical unloading procedures.

Chairperson Vanessa Allen Sutherland said, “High risk operations, like the delivery and handling of hazardous chemicals, require strict adherence to safety protocols. An inadvertent mixture can result in a chemical reaction with extremely dangerous consequences. Our findings reaffirm the need for facilities to pay careful attention to the design and operation of chemical transfer equipment to prevent similar events.”

  • The CSB’s final report includes 11 key lessons and outlines clear safety improvements that can be implemented at similar facilities across the country.  Among these are facilities should evaluate chemical unloading equipment and processes and implement safeguards to reduce the likelihood of an incident, while taking into account human factors issues that could impact how facility operators and drivers interact with equipment. 

  • Facility management should evaluate their chemical transfer equipment and processes and, where feasible, install alarms and interlocks in the process control system that can shut down the transfer of chemicals in an emergency.

For more information, copy and paste the following link into your browser: http://www.csb.gov/mgpi-processing-inc-toxic-chemical-release-/. To view the CSB’s safety video detailing the events leading to the release and featuring interviews by the CSB’s lead investigator and Chairperson, copy and paste the following link into your browser: http://www.csb.gov/videos/mixed-connection-toxic-result/