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April 7, 2009

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“Catalogue of errors” led to toxic vapour release

A chemicals company has been fined £60,000 in relation to two separate

incidents, which occurred as a result of inadequate planning and poor

communication, respectively.

Sitting on 3 April, Grimsby magistrates heard that Millennium Inorganic Chemicals Ltd endangered the health of members of the public some distance from its site in Stallingborough, north-east Lincolnshire, on 29 October, 2006.

During the draining of a vessel on a production plant in preparation for routine maintenance, the company failed to contain an industrial liquid, which reacted to form a corrosive vapour. About 82 litres of titanium tetrachloride (TiCI4) — a substance involved in the production process of titanium dioxide, which the company manufactures for use in plastic bags, aerospace parts, paper coatings, polymers and pigmentation for white paint — were released and became exposed to moisture present in the air. The liquid subsequently hydrolysed to produce oxychlorides and a toxic hydrogen chloride vapour.

A more serious incident was avoided owing to the quick thinking of an operator, who closed a valve and stemmed the flow of the liquid. By doing so, the operator put himself in danger, as TiCl4 was already raining down around the shut-off valve, preventing him from making a direct approach.

Despite the operator’s intervention, the release was enough to form a toxic cloud, which the wind fortunately blew over the Humber estuary. The local coastguard quickly closed the River Humber to shipping traffic until the cloud had dispersed.

HSE inspector Mike Nind, who led the investigation, said: “This was a serious incident, which had the potential to endanger the health of members of the public some distance from the site. Only the swift intervention of an operator prevented this incident from escalating.

He continued: “Our investigation uncovered a catalogue of errors and omissions by the company, including design issues, failure to adequately assess the risk, safety management failures, and inadequate supervision.

“The chain of events, which caused this escape, could easily have been avoided with better planning, supervision and careful management.”

In another incident, which occurred on 27 February that year, a mechanical engineer employed as a maintenance contractor by Millennium suffered a wrist fracture and a crushed forearm during repair work. The man was tasked with removing a gear box from a drum shaft, which rotates inside a bearing. The drum, weighing more than 8.5 tonnes, is used to remove moisture from the titanium dioxide manufactured by the company.

While he was dismantling the gear box and grinding off components, the engineer noticed that the bearing was passing through the shaft and was not fixed in position. He alerted Millennium, which asked him to inspect the bearing but failed to inform him that the drum was made buoyant by liquid in a sump underneath.

As he unscrewed the bearing cap, the buoyancy caused the shaft to force the cap upwards and it shattered, owing to a brittle fracture around one of the screws. The engineer’s arm became trapped between the bearing cap and some structural metal work, and he was eventually freed after a worker used a scaffold pole to lower the drum.

HSE inspector John Moran told SHP the company had failed to inform the engineer or his employer, Jex Engineering Services, that there was sufficient liquid in the sump to displace the weight of the drum. The hazard could have been eliminated at no cost or effort, simply by turning a drain valve.

Inspector Moran commented: “Risks to the employees of contractors were not being thoroughly assessed, and there was no reliable system in place to communicate the measures that were needed to control risks.

“Such measures were particularly important in this instance because the contractors were unfamiliar with the detailed working of the plant, and so were reliant upon Millennium to clearly communicate the actions that should be taken to make the plant safe before work began. Millennium did not do so.”

Pleading guilty at Grimsby Magistrates’ Court, the company was fined £40,000 for a breach of s2(1) of the HSWA 1974, in relation to the toxic-cloud incident, and £20,000 to a breach of s3(1) of the same Act over the drum incident. Costs of £25,000 were levied.

In mitigation, the company showed the court some examples of its lost-time injury rates as evidence of its good performance in this area. It also presented its company accounts, which showed that it has been making a loss in recent years.

Approaches to managing the risks associated Musculoskeletal disorders

In this episode of the Safety & Health Podcast, we hear from Matt Birtles, Principal Ergonomics Consultant at HSE’s Science and Research Centre, about the different approaches to managing the risks associated with Musculoskeletal disorders.

Matt, an ergonomics and human factors expert, shares his thoughts on why MSDs are important, the various prevalent rates across the UK, what you can do within your own organisation and the Risk Management process surrounding MSD’s.

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