ACCIDENTAL RELEASE AUDIT
INTERNATIONAL PAPER COMPANY
ANDROSCOGGIN MILL
JAY, MAINE
APRIL 20-27, 1988
PREPARED BY:
U.S. ENVIRONMENTAL PROTECTION AGENCY - REGION I
ENVIRONMENTAL SERVICES DIVISION
60 WESTVIEW STREET
LEXINGTON, MASSACHUSETTS
02173
DATE OF EXECUTIVE SUMMARY: 11/30/88
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EXECUTIVE 8UMMARY
On April 20-27, 1988, the U.S. Environinenta]. Protection Agency
(EPA) conducted an in-depth Accidental Release Audit of
International Paper Company’s Androscoggin Mill (IP). The
facility is an integrated bleached kraft mill which manufactures
coated and uncoated white and colored papers for magazines and
business applications. It also produces carbonizing tissue and
forms paper.
The purpose of the audit was to investigate the causes of the
releases at this specific facility and the equipment, procedures,
training, and management techniques utilized to prevent or
mitigate these releases. The evaluations made were based on a
comparison with available release potential technology and not on
the general practices of the paper industry. The intent of this
audit was to provide IP with information to enhance chemical
safety practices at the facility and reduce the likelihood of
future releases.
The mill utilizes a multitude of chemicals in the manufacturing
process. Many of these chemicals are considered hazardous and
extremely hazardous, and their use can result in serious safety
and environmental consequences unless proper safeguards and
prevention measures are routinely implemented. A firm commitment
to preventing chemical releases, beginning with high-level
corporate management, is a prerequisite to health and safety and
environmental protection at IP. This is especially important
because the facility is located within one mile of businesses and
residences. Schools are located within two miles of the mill.
There are approximately 5,000 people within a five-mile radius of
the facility, and more than 1,000 people are employed at IP. The
mill is located on the banks of the Androscoggin River, a
sensitive environmental area. The populace and environment are
within the impact area of chemical releases.
The audit results demonstrate the lack of adequate performance by
IP management and staff on chemical emergency preparedness and
accident prevention. This report describes numerous accidental
releases at IP which have occurred over the past two years. Some
of these releases posed a direct threat to the surrounding
community and environment. The number of releases and their
frequency of occurrence shows the lack of proper prevention
systems. Field observations document that sufficient corrective
measures have not been implemented to minimize the probability
of future chemical releases. Recommendations to improve safety
are contained in Section 13.0 of this report.
Our observations provide a snapshot of the conditions that
existed at the mill during the audit period, and are not a
substitute for a comprehensive safety evaluation program.
International Paper has informed EPA that safety enhancements
have been made since the audit and that many of the Audit Team’s
recommendations have been followed.
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The audit was conducted under the authority of the Comprehensive
Environmental Response, Compensation, and Liability Act (CERCLA),
as amended by the Superfund Amendments and Reauthorization Act
(SARA); Clean Air Act (CAA); Resource Conservation and Recovery
Act (RCRA); and EPA’s Accidental Release Information Program. It
was fully coordinated with the numerous State and Federal
agencies having jurisdiction over the facility. Comprehensive
information sharing occurred among the various agencies so as not
to duplicate efforts and to maximize utilization of the limited
amount of resources devoted to the audit. The Federal Emergency
Management Agency (FEM ) conducted the alert and notification
portion of the audit; their report is available from the FEMA
Region I office. FEMA is located at the J.W. McCormik Post
Office Building and Courthouse in Boston, Massachusetts.
International Paper cooperated in the Accidental Release Audit
and provided EPA with all necessary information upon request.
The facility has made significant improvements in preparedness
and prevention systems over the past several months. Many
improvements were being made during, and as a result of, the
State and Federal audits and investigations that have occurred at
IP over the past several months. Although improved safety may
have resulted from the audit process, additional measures are
necessary because of the history of releases at the facility and
the potential for severe environmental and safety consequences,
both at the mill and in the community.
The audit team identified twenty-one major chemical emergency
preparedness deficiencies. These deficiencies are discussed in
the body of the report and are summarized below:
1. ACCIDENT INVESTIGATIONS AND FOLLOW UP
Accident investigation procedures are inadequate. International
Paper does not adequately investigate potential and actual
chemical releases using checklists, codes, standards, or formal
techniques. Their existing accident investigation techniques
fail to adequately assess system reliability, state—of-the-art
technology, and the magnitude and probability of the accident
reoccurring. Appropriate investigation and follow up was not
initiated for major releases that involved significant worker
safety issues and major community impact. The documentation of
several accidents which occurred at the mill over the past two
years was incomplete.
Accident investigation techniques at IP must be improved to
reassure the public that appropriate changes to defective
equipment, training, and policy are implemented and that long-
term safety considerations are paramount in the accident
investigation process.
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2 • CHLORINE DIOXIDE STORAGE AND TRANSFER DESIGN CHANGES
On February 5, 1988, IP released approximately 100,000 gallons of
chlorine dioxide from a storage tank over a two-hour period. The
release occurred when maintenance workers cut an overhead steel
support without having first properly secured their work area.
This caused the pipe to fall and sheer an FRP dump nozzle on a
158,616-gallon chlorine dioxide storage tank. The gas plume
reportedly migrated beyond property lines within minutes after
the release. Chlorine dioxide is a highly unstable, toxic health
hazard which can spontaneously, and under certain conditions,
react explosively with air. See Section 9.3.3 for further
details.
The long-term prevention technique used by IP was to permanently
block off the broken valve. International Paper failed to
provide adequate assurance that the chlorine dioxide storage and
transfer system is likely to continue operating in a failsafe
mode. The mill did not determine how the valve removal impacted
overall system safety. This important design change was
completed without the necessary hazard assessment. The changed
design does not allow for efficient product transfer in the event
of a process upset or emergency.
It is necessary that I? reevaluate the chosen prevention strategy
and determine the need to implement further failsafe design to
the chlorine dioxide storage and transfer operation. The study
and design changes should, at a minimum, consider the following:
o smaller tanks with more total capacity for emergency
puildown and balance;
o backup pumping capacity;
o close fit, protected valves, discharge blanked;
o dump procedures and secondary containment; and
o floating roof and vapor control.
3. ANNONIA STORAGE AND TRANSFER DESIGN CHANGES
On November 6, 1987, IP released 3,700 pounds of anyhydrous
ammonia in approximately ten minutes. Ammonia gas is flammable,
toxic, and can be explosive. It is considered an extremely
hazardous substance. The release was caused when personnel
failed to follow a proper lock-out tag-out procedure prior to
recommissioning the ammonia transfer system (see Section 9.2.2).
International Paper did not provide the Audit Team adequate
documentation to assure that reoccurrence of the event is not
likely. The arrangement of pipes and valves could not be
adequately explained by IP. Supervision of the unloading
operation, lock-out tag-out procedures, pipe and valve
identification, and safety equipment remained deficient at the
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time of the audit.
International Paper must assess measures and implement design
changes to prevent a similar incident from occurring. The
assessment should, at a minimum, include the following:
o improved lock—out tag—out procedures;
o improved unload supervision;
o proper written unload procedures;
o process and load line separation;
o backf low check valve installation;
o labelling and color coding;
o overfill protection; and
o provisions for fire extinguishing.
4. V-BRITE HMIDLING
On April 18, 1987, IP released approximately 100 pounds of sulfur
dioxide (SO 2 ) over a six—hour period. This release occurred as a
result of a fire in a sodium hydrosulfite (V-Brite) tote bin
(see Section 9.1.3). V-Brite is used by the mill as a bleaching
agent. The product is relatively stable provided it does not
contact moisture. A small amount of water in the tote bin, along
with the presence of oxygen, can cause flammable and explosive
decomposition and the release of SO 2 gas. Sulfur dioxide gas is
immediately dangerous to life and health at concentrations of 100
parts per million (ppm). Vapors may cause burns, dizziness, and
suffocation.
International Paper implemented major design changes to prevent
future V-Brite accidents. These included the weatherizing and
enclosing of the V-Brite storage and dispensing areas. However,
the mill failed to complete an acceptable safety review and final
certification for the new design.
International Paper must initiate a post—modification safety
review which should, at a minimum, address the need for the
following:
o activation of a reaction detector thermocouple in the bin
discharge system;
o temperature and humidity monitoring;
o relocation of the emergency exhaust vent (vent should not
exhaust into a traffic area);
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o improvement of training programs and warnings for V-Brite
powder and SO 2 gas; and
o implementation of additional measures to keep the V-Brite
dry during transport from storage and dispensing areas.
5 • CHLORINE AND CHLORINE DIOXIDE SCRUBBING SYSTEMS
Hazardous chlorine and chlorine dioxide gases from process and
upset conditions throughout the mill are scrubbed by a primary
and secondary packed, countercurrent spray tower. The units are
located in series, with primary and secondary units for both the
A and B plants. The scrubbing medium is caustic from the washer
35 Filtrate tank.
International Paper did not provide sufficient evidence to
demonstrate the effectiveness and efficiency of the scrubbers in
removing hazardous chlorine and chlorine dioxide emissions.
Operational deficiencies observed during the audit are listed
below:
o Water is substituted for washer 35 Filtrate on occasion
(e.g., during startup and shutdown), resulting in inadequate
gas scrubbing on routine and upset emissions.
o Plugging, gas channeling, and maintenance problems are
likely due to fiber buildup from the washer 35 Filtrate.
o No stack emissions tests or efficiency test information was
available to certify acceptable gas emissions under normal
and accidental loads.
o No limiting operating parameters have been established as
set points for proper removal efficiency.
o No parameter monitoring gauges have been installed to assure
and record proper operation. The system should be equipped
with the proper instrumentation, for example, flow,
pressure, pH, oxidation reduction potential (ORP),
temperature, etc. A recorder should be available to monitor
off-specification parameters and bypass conditions.
o The A plant primary scrubber was not in operation during the
audit.
o Excessive moisture, condensate, and system leaks were
observed (e.g., from duct work).
o Numerous bypass lines were observed entering the system.
o The drain sections of the B plant primary and secondary
scrubbers were improperly vented to the atmosphere.
o The efficiency of the scrubbing medium needs improvement.
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International Paper should carry out comprehensive scrubber
design evaluations and stack testing to determine the extent of
modifications or design changes necessary to assure that chlorine
and chlorine dioxide gas releases from the scrubber stacks are
within acceptable levels.
6, ENVIRONMENTAL COMPLIANCE
The Audit Team conducted a review of government files to
determine IP’s environmental compliance status. Results of this
review indicate that the mill is operating with air and water
licenses and permits that require revision and renewal. There
have been numerous wastewater violations and treatment plant
bypasses. Past environmental problems were identified,
including contaminated groundwater wells MW78 and 8B and
hazardous waste storage and disposal problems. The Team
collected complaints from previous employees, alleging past
illegal hazardous waste disposal in landfills owned by IP.
These compliance issues should be pursued by multi-media
government enforcement teams. Enforcement of delegated programs
is the primary responsibility of the State of Maine. The EPA
provides enforcement assistance to the State upon request.
7 • HAZARDS ANALYSIS
Although initial steps have been taken to identify plant hazards,
the size, complexity, and off-site ramifications require more
sophisticated hazards analysis capabilities at IP. These
capabilities did not exist at the time of the audit. Improved
methods of analysis must be available for certain hazardous
material lines at the research and development stage and
conceptual and detailed design, as well as operational, phases.
Methods include checklists, independent safety audits, “what if”
analysis, failure modes, effects and criticality analysis, and
hazard and operability studies. For example, a comprehensive
hazards/risk analysis should be conducted prior to any
implementation of changes to the chlorine dioxide storage and
transfer lines.
8. DISPERSION MODELING
Dispersion modeling has not been conducted satisfactorily to
determine potential community impact from releases. This type of
analysis is necessary given EPA’S preliminary dispersion
calculations conducted in conjunction with the audit and the
nature of operations at IP. Properly selected and calibrated
modeling must be completed using accepted methods and techniques.
Release geometry, heavier-than-air gases, terrain and phase
change effects, and downwash should be considered.
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9 • FIRE BRIGADE AND HAZARDOUS MATERIALS RESPONSE
The Fire Brigade does not have the necessary expertise, training,
and equipment to effectively deal with hazardous chemical
releases. Although significant improvements have been
accomplished in these areas, IP must continue efforts to build
capabilities in accordance with an acceptable timetable. Mutual
Aid capabilities need improvement as well. Inspections and
drills must be conducted in conjunction with Mutual Aid
responders on a regularly-scheduled basis. Hazardous materials
controls, such as foam, are not available at the Brigade, and
more emphasis should be placed on personal protective equipment
and monitoring instrumentation for Brigade and Hazmat Team
members.
10. CONTINGENCY PLANS
Contingency plans are not sufficient to prepare the mill and the
community for a hazardous materials emergency. Although
significant advances have been accomplished by IP over the past
several months, the existing contingency plans must be completed,
coordinated, certified by company and community officials,
tested, and maintained.
11. ALERT AND NOTIFICATION
Alert and notification procedures within the mill are deficient.
Procedures and equipment must be upgraded to ensure that
notification is provided to affected parties for all stages of
alerts. Deficiencies observed included failure of personnel to
hear signals and malfunctioning beacons. Additionally, critical
area alarms are manually actuated and subject to human error.
There are no set criteria for determining when the alarms should
be sounded.
Alert and notification for the community is inadequate. For
example, the community was not notified of an ammonia release
which occurred on 4/9/88. The community fire department is not
automatically placed on standby or even notified, depending upon
the release situation. Community relations, Mutual Aid
notification, and response need major improvements. Additional
observations and conclusions can be found in the FEMA report.
12 • HAZARDOUS MATERIALS UNLOADING OPERATIONS
Hazardous materials unloading operations need improvement.
Surveillance, supervision, and security need upgrading. Leak
detection procedures should be routinely used for hydrogen gas
hookup in the power plant. Bulk chlorine derailers and valves
should be locked when not in use. The use of unload supervision,
escorts, written procedures, and checklists should be implemented
for dangerous unloading operations.
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13. TRAINING
International Paper has been training their employees in on-the-
job safety for many years, but a formal, written training program
is still in the early stages of development. Some training
courses have not been completely developed, and employee training
records appear to be sporadic. A more complete written training
program and recordkeeping procedure should be provided to ensure
that all employees receive the required training.
Some of the training materials requested by the Audit Team were
not reviewed because they were not immediately available at the
time of the audit. These include employee training records,
course content lists, and refresher training information. The
information that was provided included: a general training
manual; a safety practices guide; the International Paper Safety
Policy Manual, the Pulp Mill Safety Manual; and other general
training documents.
14 • DECONTAMINATION
No formal program for decontamination procedures or training was
in place at the time of the audit. It is recommended that IP
institute a comprehensive, mill—wide program, to include the
following: planning, training, implementation, and establishment
of designated decontamination zones.
15. ACCOUNTABILITY FOR CONTRACTORS
Training and safety must be improved for contractors and outside
visitors during both routine and emergency situations.
International Paper should assume more responsibility to protect
these groups and must enforce standards similar to those required
of IP personnel.
16. REACTIONS TO SIMULATED EMERGENCIES
The emergency drill conducted at the request of the Audit Team
identified deficiencies in the following areas: command and
coordination; communication; notification; and response.
Simulations involving community planners and responders are not
conducted. Regular drills are necessary to improve safety
implementation and coordination consistent with the provisions of
SARA Title III.
17 • MONITORS AND ALARMS
The one chlorine monitor currently in operation in the pulp area
does not provide adequate monitoring coverage. International
Paper is presently installing sixteen sensors throughout the
area. However, they will all operate with the same central
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alarm. This system will require testing and evaluation once
installation is complete. Area sensors should be activated
automatically rather than from the control room. International
Paper needs to develop a system for inspecting, maintaining, and
calibrating the detectors. A backup alarm or other provisions
should be considered to reduce the possibility of central alarm
failure. The expanded network installation schedule should be
“fast tracked” to provide increased release detection and safety.
18. EMERGENCY BACKUP POWER
Adequate provisions have not been made for emergency,
uninterruptible power on hazardous materials alarms, sensors, and
other emergency services. International Paper has significant
flexibility in obtaining power through three manually-switched
two-way busses. Wood, oil, and hydroelectric capabilities, as
well as the mill’s ability to purchase from the power grid, are
available. However, area power outages have caused water
treatment plant bypasses and chemical releases to the
environment. International Paper should initiate a study to
identify improvements in power shedding and utility reliability.
Emergency standby power should be available for the alarm and
notification system. As a part of their emergency backup power
study, IP should review solid state controlled automatic
switching of their present manually-switched two way busses.
19, FAIL-SAFE INTERLOCKS ND VALVING
A cursory review of critical interlocks and valves identified
possible deficiencies in both A and B bleach plants. Drawings
and follow up discussions indicated that upon power failure,
several valves may fail to an unsafe position. Many of the
diagrams presented to the Audit Team were outdated or inadequate
for conducting an accurate interlock and valve safety review.
Because of the issues raised, we recommend that IP conduct a
comprehensive interlock and valve safety study. Modifications
should be initiated, where necessary.
20. OPERATION AND MAINTENANCE PROCEDURES
The Preventative Maintenance program for equipment used in
hazardous materials lines should be upgraded to include routine
replacement of critical parts based on the history of failure
rather than waiting for the equipment to fail while in service.
This program will require time to implement because IP has only
recently begun to keep accurate records on corrosion allowance,
release valve checks, and other critical maintenance items.
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21. METEOROLOGICAL MONITORING
Realtime meteorological monitoring data from the 100 -meter tower
is not currently available at the mill’s emergency response
command post. This information would be critical in the event of
a serious emergency release. International Paper should
prioritize this project and bring the system on line as soon as
possible.
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CONCLUSION
The primary purpose of the Accidental Release Audit was to
identify imminent or potential hazards to the community and the
environment and to recommend corrective measures. As a result of
recent multi-media agency inspections, IP has improved risk
management procedures and has demonstrated an effort to improve
release prevention and safety. However, several potentially
serious safety problems were identified within the plant and its
environs. International Paper should evaluate the outlined
recommendations in this report as a means to substantially reduce
the risk of occupational and community-related injuries which may
occur as the result of a chemical accident or release.
MP/bps
2O29exec.rpt(85)
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