U.S. Chemical Safety Board Releases New Safety Video on Fatal Hydrogen Chloride Release at the Wacker Polysilicon facility in Charleston, Tennessee
Washington D.C., October 17, 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 hydrogen chloride at the Wacker Polysilicon North America facility in Charleston, Tennessee, that occurred on November 13, 2020. One contract worker was killed - and two others were seriously injured - when attempting to escape the release.
The CSB's new safety video, called “No Way Down: Chemical Release at Wacker Polysilicon,” includes an animation of the events leading to the incident, as well as commentary from CSB Board Member Catherine Sandoval and CSB Lead Investigators Tyler Nelson and Drew Sahli.
The CSB released its final investigation report on the incident at Wacker on June 15, 2023. The CSB’s investigation found that at the time of the incident there were multiple contract workers present on the fifth floor of an equipment access platform at the facility. The contract workers were from two different firms, conducting different work, and were wearing different levels of Personal Protective Equipment. One of the workers applied excessive torque to flange bolts on a heat exchanger outlet pipe containing hydrogen chloride, causing the pipe to crack and release the hazardous chemical in the vicinity of the workers. There was only one way to exit the platform – via a staircase. As the white cloud of hydrogen chloride expanded, the workers on the platform were not able to see their surroundings or access the staircase. Three of the workers who were not wearing full-body chemical resistant suits began climbing down the side of the structure to escape the hazardous cloud. All three workers fell approximately 70 feet during their attempt to escape. One of the workers died from the fall, and the other two sustained serious injuries. In the safety video, Board Member Catherine Sandoval says, “This tragic incident was completely preventable.” She added: “What should have been fairly straightforward maintenance activity by two separate groups of workers turned deadly because of several serious safety issues. The CSB believes that our findings and recommendations will address the issues found at Wacker and prevent another needless tragedy.”
The safety video addresses the key safety issues identified in the CSB’s final report that contributed to the incident: (i) the need for written procedures, (ii) control of hazardous energy, (iii) greater guidance on simultaneous operations, and (iv) improved means of egress. The video also highlights safety recommendations made by the CSB to Wacker Polysilicon, the Occupational Safety and Health Administration, the Center for Chemical Process Safety, the International Code Council, and the National Fire Protection Association.
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.
来源：CSB
高风险作业安全能力提升(HHC)
High Hazard Coordinator (HHC) Workshop
中国上海（可在线学习）
12/2~3
课程特点
基于高风险作业风险管理最佳实践；
结合知名跨国化工企业高风险作业安全管理协调员能力提升实战经验，以及国内相关要求；
课程主要讲解作业许可要求、坠落预防和保护、动土作业安全、空气检测、危险能量控制和上锁挂牌安全、开管作业安全、动火作业安全、受限空间进入安全和受限非进入式救援技术；
全面提升学员对于高风险作业危害识别和危害控制的能力；
合理安排循序渐进、环环相扣的高风险作业危害识别、风险管控措施及应急管理实践；
穿插讲解著名跨国外企在高风险作业安全管理方面的最佳实践案例。
谁应该参加
厂长、营运经理、车间主任、生产主管、工程师及领班；
EHS总监、EHS经理、安全主管和安全工程师；
维修经理、维修工程师和项目工程师；
工程经理、项目经理和技术员。
准备
安全分享
参加人员介绍/分组研讨会规则
研讨会内容简介
第一部分：高危作业事故案例及国标要求
¢国内高风险作业事故分享（动火、受限空间、登高作业、能源控制/上锁挂牌）
¢定义（火作业、高处作业、受限空间作业、盲板抽堵、动土作业）
¢国标要求（通用要求、动火作业、高处作业、受限空间作业、盲板抽堵、动土作业等）
第二部分：工作许可
¢危害控制措施：控制层级概念
¢小组活动：应用控制层级方法讨论动火、受限空间进入、开管作业、能量隔离上锁挂牌活动的控制措施
¢高风险作业许可的基本/通用要素
¢许可证细节
¢签发人：你需要知道……
第三部分：坠落预防和保护
¢何时需要坠落预防和保护
¢固定式直梯坠落预防
¢移动作业平台的危害
¢屋顶坠落保护
¢个人坠落保护设备
¢移动梯
¢装卸工作站
¢其他考虑因素
第四部分：（动土）挖掘作业安全
¢挖掘作业概述
¢挖掘危害
¢预防塌陷危害的三种方法
¢设置防护边坡
¢土壤的威力
¢表面堆积物
¢地下设施危害
¢进出口
¢挖掘作业与密闭空间作业类似点
¢救援需求
¢危害识别活动
第五部分：空气监测
¢三种气体危险
¢什么是气体
¢氧气、爆炸下限、一氧化碳、硫化氢气体特性
¢测量仪表如何工作
¢电化学传感器
¢催化传感器
¢便携式气体测量仪
¢光离子化检测器PID
¢比色管
¢使用，校准，Bump测试
¢气体监测要求
¢监测时机和流程
¢监测顺序
¢附件和采样仪器
¢将测试结果记录在许可证上
¢暴露限值
第六部分：危险能量控制和上锁挂牌LOTO
¢什么是上锁?
¢危险能量的类型
¢何时需要锁定呢？
¢LOTO相关定义
¢危险能量控制和上锁挂牌要求
¢能量隔离设备、锁具和挂牌
¢上锁挂牌(LOTO)八大基本步骤介绍
¢具体设备锁定程序和LOTO许可证
¢上锁许可证练习
¢危险能量控制的特殊情况
¢移除锁具-特殊情况
¢测试和调试
¢小组锁/锁箱
¢小型服务和调整
¢上锁挂牌的替代方法
¢年度程序评估
¢承包商
¢回顾
¢流体隔离方法
¢密闭空间的隔离
¢隔离方法
¢其他考虑因素
第七部分：开管作业
¢开管作业概述
¢开管作业定义
¢例外情况
¢开管危害
¢开管相关程序
¢典型要求和职责
¢开管作业许可证及要求
¢开管作业PPE要求
¢开管作业的5个步骤
¢识别化学和物理介质
¢隔离管道/设备
¢泄压并排空物料
¢冲洗和/或吹扫物料
¢确认隔离的完整性
¢带压设备管线的开管指南
¢练习编写开管作业许可证
第八部分：动火作业
¢为什么需要动火作业管理程序？
¢动火作业程序要求
¢相关定义
¢带压打孔
¢指定固定动火区管理要求
¢动火作业许可证
¢需要许可的活动
¢动火作业许可证准备工作
¢气体监测
¢许可作业现场检查和批准
¢许可证过期和终止
¢焊接和切割活动典型危害及安全要求
¢动火作业危害识别
¢动火作业安全标识
¢动火作业个人防护用品
¢个人防护用品危害评估
¢身体各部位的防护要求
¢清理现场和准备动火作业-清理、通风、惰化
¢火灾预防、保护和动火监视
¢动火作业许可-空气监测及结果记录
¢动火监护-特殊情况
¢CSB列出的7个关键教训
¢练习编写动火作业许可证
第九部分：密闭空间(CSE)进入
¢密闭空间进入标准
¢密闭空间进入定义
¢进入前和作业期间气体检测
¢允许的空气条件
¢监护要求
¢密闭空间进入相关活动的培训要求
¢救援要求
¢密闭空间WSBC 1 – 录像
¢CSE术语、角色、职责
¢密闭空间定义和举例
¢什么是进入？
¢职责：密闭空间进入协调员
¢职责：监护人
¢监护人严禁事项
¢进入人员的危险信号和症状
¢监护人气体监测要求
¢监护人救援程序
¢熟悉与密闭空间相关的设备
¢监护人职责小结
¢救援人员职责小结
¢授权的进入人员职责
¢进入的准备要求
¢救援评估表
¢进入CSE空间内部救援计划检查表
¢进入的准备要求-PPE
¢密闭空间的主要危害
¢为什么只靠阀门不能隔离的例子
¢CSE作业实践-清理
¢CSE作业实践-工具和设备
¢CSE作业实践-通风
¢密闭空间 WSBC 3 – 录像
¢练习:受限空间进入许可证
第十部分：受限空间救援技术
¢CSE进入救援要求和问题
¢为什么救援？
¢非进入救援——优点
¢非进入救援方法
¢上方悬挂点
¢救援系统
¢机械优势系统
¢设备描述和功能——三脚架
¢救援系统——简单滑轮系统
¢设备描述和功能——绞车
¢设备描述和功能-五点式安全带
