Chemical Engineering November 2013 - 169

Fractionation Column
Environmental Manager
A repeat near miss
I
t is with extreme reticence that I
author this page, even though I received
permission several months
ago to do so. FRI had a near miss
in 2010, which was identical to a
near miss that occurred in 2007. In
the safety world, such things should
never happen.
In 2007, FRI was running butanes in
its high-pressure test column. A gasket
blew, releasing butanes to the atmosphere;
the butanes did not ignite.
Shortly thereafter, one FRI employee
sent an email with six brief questions
to another FRI employee. The second
employee responded with six brief
answers. That was the full extent of
the investigation and documentation.
Following that incident, a certain mythology
developed around it. For many
months after the incident, staff members
referred to a " window failure " as
the cause of the release. In fact, the
cause of the release was a gasket failure.
Virgin Teflon gaskets had been
supplied inappropriately by a vendor.
In November of 2010, there was another
butanes release from the highpressure
test column. All of the appropriate
government agencies were
informed immediately. An investigation
was initiated immediately. It took
several months, but it was ultimately
determined that the exact same vendor
had supplied the exact same (and
inappropriate) virgin Teflon gaskets.
Other vendors graciously assisted with
the investigation, which included a
chemical analysis of the 2010 gaskets.
The 2010 investigation also included a
review of the too-brief documentation
of the 2007 " window incident " which
was truly a " gasket incident. " The entire
organization was embarrassed to
find out that the same thing had happened
twice.
The 2010 investigation also revealed
the following about the 2007 investigation:
The results were not properly
distributed to the staff members; the
action items were unclear; there was
zero long-term follow-up; the 2007
vendor might not have been informed;
and the vendor was not changed. The
2010 investigation resulted in the longest
safety investigation and report
in the company's history. None of the
mistakes of the 2007 investigation
was repeated.
As an extra response to the second
incident, FRI contracted for a professional
dispersion study. That study
identified the paths that butanes
might take during any future (and
preventable) releases. For winter and
summer conditions, that study estimated
the flammability potentials
along the paths.
FRI's attention to safety seems to
increase in quantum steps every ten
years. This also seemed to be true at
the companies that I worked at before
joining FRI. For all of us, the next
ten years will probably bring another
valuable quantum step.
When looking back on both incidents,
another lesson seems to be
available to us. Sellers sell and buyers
Mike Resetarits is the technical director
at Fractionation Research, Inc. (FRI;
Stillwater, Okla.; www.fri.org), a distillation
research consortium. Each month,
Mike shares his first-hand experience
with CE readers
buy. Both parties are totally responsible
for the protection of their employees,
their neighbors, the environment
- and their customers.
■
Mike Resetarits
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Chemical Engineering November 2013

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