WASHINGTON, D.C., U.S. — The U.S. Chemical Safety Board (CSB) on Jan. 3 released a 48-page case study examining the incident that took place on Oct. 21, 2016, at a MGP Ingredients, Inc., facility in Atchison, Kansas, U.S. The CSB also has published a video detailing key lessons learned from the incident.

As part of the incident, a mixture of incompatible materials resulted in a chemical release containing chlorine and other compounds traveling into the community. The cloud affected workers onsite and members of the public in the surrounding community. The incident occurred during a routine chemical delivery of sulfuric acid from a Harcros Chemicals (Harcros) cargo tank motor vehicle (CTMV) at the MGPI facility tank farm.

Over 140 individuals, including members of the public, MGPI employees, and a Harcros employee, sought medical attention; one MGPI employee and five members of the public required hospitalization as a result of exposure to the cloud produced by the reaction.

In the report, titled “Key lessons for preventing inadvertent mixing during chemical unloading operations,” the CSB identified 11 key lessons from the incident, and outlined clear safety improvements that can be implemented at similar facilities across the United States.

Among the lessons, the CSB said, are that facilities should evaluate chemical unloading equipment and processes and implement safeguards to reduce the likelihood of an incident, while taking into account human factors issues that could impact how facility operators and drivers interact with equipment. Additionally, facility management should evaluate chemical transfer equipment and processes and, where feasible, install alarms and interlocks in the process control system that can shut down the transfer of chemicals in an emergency, the CSB noted.

“High risk operations, like the delivery and handling of hazardous chemicals, require strict adherence to safety protocols,” said Vanessa Allen Sutherland, chair of the CSB. “An inadvertent mixture can result in a chemical reaction with extremely dangerous consequences. Our findings reaffirm the need for facilities to pay careful attention to the design and operation of chemical transfer equipment to prevent similar events.”

Lucy Taylor, lead investigator on the MGPI case, added, “Facilities need to work collaboratively with their chemical distributors to conduct a risk assessment and develop and agree upon procedures for chemical unloading to ensure responsibilities are clearly defined.”