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Occupational Safety and Health Administration OSHA

Accident Report Detail

Accident: 14392450 - Seven Employees Hospitalized After Chlorine Release

Accident: 14392450 -- Report ID: 0625700 -- Event Date: 03/05/1991
InspectionOpen DateSICEstablishment Name
11042046003/06/19912621Mansfield'S Industrial Coatings Inc.
InspectionOpen DateSICEstablishment Name
10891427603/14/19911791James Machine Works, Inc.
InspectionOpen DateSICEstablishment Name
10891426803/13/19911721Mansfield Industrial Coatings Of Fla, Inc.
InspectionOpen DateSICEstablishment Name
11042046003/06/19912621Mansfield'S Industrial Coatings Inc.
InspectionOpen DateSICEstablishment Name
10891427603/14/19911791James Machine Works, Inc.
InspectionOpen DateSICEstablishment Name
11042046003/06/19912621Mansfield'S Industrial Coatings Inc.
InspectionOpen DateSICEstablishment Name
10891427603/14/19911791James Machine Works, Inc.
InspectionOpen DateSICEstablishment Name
10891416903/13/19911629Be&K Construction Company
InspectionOpen DateSICEstablishment Name
10891427603/14/19911791James Machine Works, Inc.
InspectionOpen DateSICEstablishment Name
10891416903/13/19911629Be&K Construction Company
InspectionOpen DateSICEstablishment Name
10891427603/14/19911791James Machine Works, Inc.
InspectionOpen DateSICEstablishment Name
10891428403/06/19912621Mansfield'S Industrial Coatings Inc.
InspectionOpen DateSICEstablishment Name
10891416903/13/19911629Be&K Construction Company
InspectionOpen DateSICEstablishment Name
11042046003/06/19912621Mansfield'S Industrial Coatings Inc.
At approximately 12:00 noon on March 5, 1991, at the Louisiana mill of International Paper, three 90 ton chlorine tank cars were at the loading area. Two pulp mill employees hooked up the east chlorine car. They tested for leaks and detected none. Upon entering their work station, approximately 100 ft north of the car, they heard a local alarm at the chlorine cars. With gas masks and a personal chlorine monitor, they returned to the car. They found a small leak at a valve packing on the car. Because even the smallest leaks are enough to activate the monitors, which are set at 0.5 ppm, they assumed they had found the source. One employee returned to the work station to get a wrench to tighten the packing. The remaining employee then noticed that the pulldown line had begun to ice up. He looked at all three pulldown valves on the car and each appeared to be closed. He pushed up on them to be sure. At that time, the high ORP alarm on the hypo collecting tank in the bleach plant sounded in the control room. The control room operator cut the chlorine off the bleach liquor maker and had the chlorine hand valve also cut off. He paged the employee at the car, who went to the two chlorine vaporizers and opened and closed each pulldown valve to be sure they were closed. The operator, at this time, realized that a significant emission had occurred but was now stopped. The employees estimate that 3 to 5 minutes elapsed from the time they finished hooking up the car until the valve on the south vaporizer was opened and closed. Total released chlorine was estimated to be between 500 and 1,200 lb. Five International Paper (IP) employees were in a pickup truck returning to their jobs. They were on the east side of the evaporator proceeding north when the release occurred. There was a strong wind blowing from the south; the driver stopped the truck just south of the evaporator cooling tower. All five employees got out of the truck and four proceeded north. Of the four who proceeded north, three were hospitalized. A driver of a dumpster truck ahead of the pickup was hospitalized, although his passenger was not. He had driven north until he thought he was out of the chlorine. An employee on a bicycle just ahead of the dumpster needed cough syrup, but was otherwise unaffected. Three contractor employees, who were working and eating lunch approximately 200 feet northwest of the blowdown, were hospitalized. An additional three IP employees and ten contractor employees were treated at Mill Health Services. Thirteen BE&K employees were treated at their first aid station. No IP employees had respirators with them because they were only passing through the area and not leaving the road. All hospitalized contractor employees used respirators, but used them too late to be effective. Inspection of the pulldown valve on the south vaporizer showed that the stop on the valve handle was incorrectly positioned so that the vale was partially open when it appeared to be closed. Also, the ORP probe alarm in the blowdown did not function because a conductor was broken.
Keywords: railroad tank car, chlorine, accidental discharge, inhalation, valve, respirator, inadequate maint
Employee # Inspection Age Sex Degree Nature Occupation
1 110420460 Hospitalized injury Other Occupation not reported
2 110420460 Hospitalized injury Other Occupation not reported
3 110420460 Hospitalized injury Other Occupation not reported
4 110420460 Hospitalized injury Other Occupation not reported
5 108914276 Hospitalized injury Other Occupation not reported
6 108914276 Non Hospitalized injury Other Occupation not reported
7 108914268 Hospitalized injury Other Occupation not reported
8 110420460 Non Hospitalized injury Other Occupation not reported
9 108914276 Hospitalized injury Other Occupation not reported
10 110420460 Non Hospitalized injury Other Occupation not reported
11 108914276 Non Hospitalized injury Other Occupation not reported
12 108914169 Non Hospitalized injury Other Occupation not reported
13 108914276 Non Hospitalized injury Other Occupation not reported
14 108914169 Non Hospitalized injury Other Occupation not reported
15 108914276 Non Hospitalized injury Other Occupation not reported
16 108914284 Occupation Not Listed
17 108914169 Non Hospitalized injury Other Occupation not reported
18 110420460 Non Hospitalized injury Other Occupation not reported

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