Failure to Plan for Emergency

FORMOSA PLASTICS CORP. blames human error for the explosion that killed five workers and seriously injured three others at its Illiopolis plant on April 23, 2004. In the narrowest possible analysis of the accident, the company is correct.

A worker at the plant cleaning an empty reaction tank mistakenly drained an adjacent tank, which was full of pressurized vinyl chloride, covering the plant floor with 18 inches of the dangerous chemical and causing its explosive fumes to quickly fill the air. A few minutes later came the explosion that was heard for miles and had tragic consequences.

BEFORE OPENING the incorrect tank, the worker had to bypass a fairly elaborate system designed to prevent just such a chemical spill. It’s easy to fault human error here. After descending a staircase to get to the bottom of the tank he was cleaning, the worker may simply have turned right instead of left and attempted to open the wrong tank. Though they were numbered, the tanks were identical and arranged in identical groups of four. Who among us hasn’t mixed up numbers on occasion? In this case, it may been a mixing up of number 306 – the tank the employee was cleaning – and tank number 310.

But tank 310′s drain valve wouldn’t open because it was full of reacting chemicals and its contents were under pressure. Rather than checking with a supervisor on why the valve wouldn’t open, the worker manually bypassed the tank’s security mechanism, which involved connection of air hoses and was intended for use only in emergencies. A massive spill of vinyl chloride resulted.

To Formosa, that is all the evidence needed to blame human error for the ensuing explosion.

WHILE HUMAN ERROR may have been a factor, however, it was not the cause of this tragedy. The real cause, as enumerated in the report issued this week by the U.S. Chemical Safety and Hazard Investigation Board, was Formosa’s failure to address the potential for human error in this process. Most damningly, the report notes numerous near misses at Formosa facilities – including one just two months earlier at the Illiopolis plant – that all but predicted a tragic accident like the one in 2004.

Much of the report’s criticism pertains to technical aspects of the PVC production process. But there also are points that relate more to common sense. The worker who released the chemical from the wrong tank did not carry a radio for communicating with a supervisor. To check why tank 310′s drain valve would not open meant trudging back up the stairs to a control area; a minor inconvenience in hindsight but certainly an easy enticement to “human error.”

As deadly vinyl chloride fumes filled the plant and alarms sounded, workers scrambled to figure out the problem and tried to stop the flow of chemical. What they should have been doing at that point was evacuating the building. Yet the plant had not had an emergency evacuation drill in 10 years. That is utterly staggering considering the hazardous nature of the plant’s raw materials. Evacuation should not have been merely something to drill, but something drummed into every Formosa employee’s mind every day: If those alarms sound, get out.

THAT SIMPLE procedure might have saved lives and serious injury the night of April 23, 2004. So might have a $20 set of walkie- talkies. So might have a number of technical enhancements that were to have been completed three weeks earlier. The sad truth is we will never know.

The Illiopolis plant probably will never open again in a manufacturing capacity. But Formosa continues to operate PVC plants in Delaware, Texas and Louisiana. For the sake of workers there, Formosa needs to stop blaming human error for this tragedy and address its failure to implement basic steps that might have prevented it.

(c) 2007 State Journal Register. Provided by ProQuest Information and Learning. All rights Reserved.