AEPA ENFORCEMENT ALERT
OFFICE OF ENFORCEMENT
AND COMPLIANCE ASSURANCE
National Compliance Initiative: Reducing Accidental Releases at Industrial and Chemical Facilities
EPA Document #300N21002	February 2021
Risk of Chemical Accidents During Process Startup
This purpose of this Enforcement Alert is to highlight the importance of accident prevention efforts during
startup periods and other times of nonroutine operations. Chemical accidents can occur at any time, but there
are times when facilities are more prone to accidents. Startup is a particularly vulnerable time. The Chemical
Safety Board (CSB) noted in its Safety Digest, "CSB Investigations of Incidents During Startups and
Shutdowns" (https://www.csb.gOv/assets/1/6/csb digest - startup shutdown.pdf) and in its Safety Alert,
"AFTER HARVEY: Precautions Needed During Oil and Chemical Facility Startup"
(https://www.csb.gOv/assets/1/20/csb harvey2017 05.pdf), that a disproportionate number of accidents occur
during startup or other nonroutine operations. Facilities should be aware of several recent incidents (described
below) that occurred during startup, so they can take extra care to avoid these types of accidents.
Legal Requirements
Preventing chemical accidents is an important responsibility for facilities that use extremely hazardous
substances. Section 112(r)(7) of the Clean Air Act and the implementing regulations at 40 CFR Part 68 require
all facilities, regardless of their size, that use certain extremely hazardous substances above a specified
quantity in a process to develop a Risk Management Program. These facilities must:
•	Conduct a hazard assessment that identifies potential effects of a chemical accident and an evaluation
of worst-case and alternative accidental release scenarios (40 CFR Subpart B);
•	Keep track of any accidents that took place in the last
five years (40 CFR 68.42);
•	Implement a prevention program that includes safety
precautions, and maintenance, monitoring, and
employee training measures (Subpart C, and Subpart
D); and
•	Implement an emergency response program that
includes coordination with local emergency responders,
procedures for responding to accidental releases,
emergency health care, employee training measures
and procedures for informing the public and response
agencies (e.g., fire departments) should an accident
occur (40 CFR Subpart E).
Subpart G of 40 CFR Part 68 also requires these facilities to
submit a written Risk Management Plan that summarizes their
Risk Management Program to the U.S. Environmental
Protection Agency (EPA). The information in a facility's Risk
Management Plan helps local fire, police, emergency response
personnel, and other stakeholders prepare for and respond to
chemical accidents. It also provides citizens with useful
information about chemical hazards in their communities.
National Compliance Initiative
While EPA routinely monitors
compliance with accident prevention
requirements and takes appropriate
action if companies are not meeting their
legal obligations to operate in a safe
manner, these requirements are also
currently the subject of a National
Compliance Initiative (NCI). Through the
NCI, EPA is increasing its compliance
and enforcement activities to ensure
companies are reducing the likelihood of
chemical accidents and improving the
response to accidents that do occur.
More information about the NCI can be
found at
https://www.epa.gov/enforcement/nation
al-compliance-initiative-reducing-
accidental-releases-industrial-and-
chemical.

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Serious Chemical Incidents Occurring During Startup
In the immediate aftermath of an accident, local fire, police and emergency responders are generally first on
the scene to respond to the fire or chemical release. That is why it is important for them to have a facility's Risk
Management Plan so that they are better prepared to respond to the hazards they might be facing. The
Chemical Safety Board investigates accidents to determine the cause or causes so that similar accidents might
be prevented. The EPA would also investigate after an accident to determine if the facility was in violation of
Section 112(r) that might have led to the incident. If it was in violation, the EPA will compel the company to
return to compliance and may assess a penalty. The following are examples of serious chemical incidents.
Fire during Startup at Phillips 66 Wood River Refinery Caused
Injury
On February 10, 2019, a fire occurred in the Distilling Unit #2 at the Phillips 66
Wood River Refinery during startup after a planned maintenance outage.
Hydrocarbons were routed to a heat exchanger, which should have been
bypassed, when operators opened the incorrect valve. The liquids flowed into
the exchanger shell side and over-pressured a bellows on the tube side,
releasing hydrocarbons through an open pipe. The hydrocarbons sprayed out
of the open pipe onto the exchanger platform structure and found an ignition
source. Approximately 50,000 pounds of the hydrocarbon flammable mixture
were released over eight minutes and the subsequent fire lasted about 50
minutes. One contractor employee was injured in the incident.
Fire during Preparations for Startup at Kuraray America Caused
Numerous Injuries
On May 19, 2018, at approximately 10:30 a.m., a fire occurred at the Kuraray America EVAL facility in
Pasadena, Texas during preparations for startup activities following a turnaround. At the time of the incident,
266 employees and contract workers were onsite. During pre-startup pressure-testing activities of a chemical
reactor, an abnormal high-pressure condition developed and over 2,000 pounds of ethylene were released to
the atmosphere from a pressure relief valve. The ethylene vapors ignited causing worker injuries. Twenty-one
injured workers were transported to off-site medical facilities for treatment.
The CSB investigation into the underlying causes of this incident is ongoing as of the date of this alert. More
information can be found at: https://www.csb.gov/kuraray-america/.
Release during Startup at DuPont La Porte Chemical Facility
On November 15, 2014, Dupont La Porte released 24,000 pounds of methyl mercaptan from vent piping at an
insecticide production plant in La Porte, Texas during startup and troubleshooting operations. The release
killed four employees and injured an additional
two employees.
The DuPont Lannate© process had undergone a
shutdown on November 10 and a portion of the
methyl mercaptan piping in the reaction section of
the process became plugged due to formation of a
solid hydrate. Plant personnel conducted
troubleshooting for several days in this section of
the plant and ultimately identified the location of
the plug and dislodged it by using hot water on the
outside of the piping. Plant personnel opened
valves from the mercaptan piping to the waste gas
vent header to relieve pressure in the system. The
Figure 2: DuPont La Porte Chemical Facility
IHHH
Figure 1: Fire at Phillips 66 Wood
River Refinery
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vent header provided an open path to the interior of a building through drain lines that would later be opened in
the troubleshooting process. When the solid hydrate began to dissolve, methyl mercaptan liquids entered the
vent header and released into the building. Multiple plant personnel who were troubleshooting the plugged
lines and responding to alarms within the building became incapacitated, eventually leading to injuries and
death.
The CSB investigated the incident and identified multiple deficiencies in the process safety management and
emergency response programs at the plant that contributed to the accident during the Lannate process start-
up. The facility's inadequate emergency response procedures and failure to maintain emergency response
equipment led to delays in the plant Emergency Response Team's ability to enter the building and respond to
the incident. The facility's 2011 process hazards analysis (PHA) identified the formation of methyl mercaptan
hydrate solids as a hazard but did not include any recommendations to address the hazard that may have
prevented the accident. The facility applied hot water to the methyl mercaptan piping and opened several
valves to the vent header without conducting a management of change (MOC) review that may have identified
the hazards. In addition, operators opened drain lines along the vent header while troubleshooting without
following safe work practices for line openings. The CSB report can be found at https://www.csb.gov/dupont-la-
porte-facilitv-toxic-chemical-release-/.
EPA and the Department of Justice recently concluded an enforcement action against DuPont for alleged
violations that led to a fatal release. As a result of that enforcement action, DuPont paid a $3.1 million penalty.
More information about this action can be found at https://archive.epa.gov/epa/newsreleases/epa-and-iustice-
department-reach-31-million-settlement-dupont-alleqed-chemical-accident.html.
Release during Startup at Williams Geismar Olefins Plant Results in Fatalities
On June 13, 2013, a reboiler on the propylene fractionator distillation column at the Williams Geismar Olefins
plant ruptured during start-up operations, releasing over 30,000 pounds of hydrocarbons that ignited and
caused an explosion and fire. The accident killed one operator on-site and a supervisor the following day,
injured 167 additional employees and contractors, and forced a shelter-in-place for the surrounding community
in a two-mile radius. A reboiler is a shell-and-tube heat exchanger that exchanges heat between quench water
on the tube-side and the recycled propylene process stream on the shell side, which vaporizes the
hydrocarbons before returning them to the distillation
column. The Geismar plant alternated between two
exchangers, Reboiler A and Reboiler B, with one
exchanger on-line and one exchanger valved out as
a spare for use if needed. Prior to the accident,
operators observed a reduced flowrate of the
quench water feeding the on-line exchanger,
Reboiler A, and suspected fouling of the water. To
take Reboiler A out of service, operators switched
valves to begin flow of quench water to Reboiler B
while keeping the shell-side valves closed. Soon
after, Reboiler B over-pressured and ruptured. The
ensuing investigation determined that hydrocarbons
had either leaked into or were inadvertently fed to
Reboiler B at some point prior to the accident and
the trapped liquids vaporized and over-pressured the
system causing an explosion.
Figure 3 Reboiler. post-accident
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The CSB investigated the incident and discovered multiple deficiencies in the process safety management
program at the plant contributed to the accident during start-up. Inadequate MOC procedures and
implementation of those procedures failed to identify the over-pressurization hazards of trapped hydrocarbons
in the exchangers introduced by installation of the isolation block valves in years prior to the incident.
Operating procedures in place at the start-up of the Reboilers were generic and did not identify the specific
valves, equipment, and sequencing of steps needed to safely start up the offline exchanger. The questions on
the pre-startup safety review (PSSR) checklist completed at the time of the valve installation were incomplete
or incorrectly answered. If correctly answered, the
hazards may have been identified. PHAs
performed on this process either did not identify
the over-pressurization hazard or safeguards to
protect from over-pressurization were not
completed. The CSB report can be found at
https://www.csb.gov/williams-olefins-plant-
explosion-and-fire-/.
The EPA and the Department of Justice settled a
civil enforcement action against Williams Olefins
for alleged violations that resulted in a fatal
accident. Williams paid a penalty of $750,000.
Audit Policy
Regulated entities of any size who voluntarily
discover, promptly disclose, expeditiously correct,
and take steps to prevent recurrence of potential
violations may be eligible for a reduction or
elimination of any civil penalties that otherwise
might apply. Most violations can be disclosed and
processed via EPA's automated online
"eDisclosure" system
(https://www.epa.gov/compliance/epas-
edisdosure). To learn more about the EPA's
violation disclosure policies, including conditions
for eligibility, please review EPA's Audit Policy
Facilities that use listed extremely hazardous
substances need to comply with these
Important Regulatory Provisions
Facilities that use listed extremely hazardous
substances need to comply with all the regulatory
provisions of 40 CFR Part 68, to the extent they are
applicable. In order to prevent accidents during
startup, the following provisions are particularly
important:
•	Operating Procedures (40 CFR 68.52 and
68.69), that provide clear instructions for safely
conducting activities involved in each covered
process.
•	Training (40 CFR 68.54 and 68.71), so that
each employee involved in operating a process
is familiar with the operating procedures, safety
and health hazards, emergency operations,
and safe work practices.
•	Pre-startup review (40 CFR 68.77), ensuring
that construction and equipment is in
accordance with design specifications, and that
safety, operating, maintenance, and
emergency procedures are in place and are
adequate.
website at https://www.epa.gov/compliance/epas-
audit-policv. Many states also offer incentives for self-policing; please check with the appropriate state agency
for more information.
Where can I get more information?
For more information, please visit EPA's Risk Management Plan (RMP) Rule webpage at
https://www.epa.gov/rmp
Disclaimer
This Enforcement Alert addresses select provisions of EPA regulatory requirements using plain language. Nothing in
this Enforcement Alert is meant to replace or revise any Clean Air Act permit, any EPA regulatory provision, or any
other part of the Code of Federal Regulations, the Federal Register, or the Clean Air Act.
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