Fatal Release of Acetic Acid and Methyl Iodide Mixture at

LyondellBasell La Porte Complex

U.S. Chemical Safety and
Hazard Investigation Board La Porte, Texas | Incident Date: July 27, 2021 | No. 2021-05-I-TX

Investigation Report SAFETY ISSUES:

Published: May 25, 2023 • Valve Design to Prevent Human
Error
• Providing Workers with
Conditions, Procedures, and
Training to Safely Conduct Work
 Investigation Report

U.S. Chemical Safety and Hazard Investigation Board

The mission of the U.S. Chemical Safety and Hazard Investigation Board (CSB) is to
drive chemical safety excellence through independent investigations
to protect communities, workers, and the environment.

The CSB is an independent federal agency charged with investigating, determining, and reporting to
the public in writing the facts, conditions, and circumstances and the cause or probable cause of any
accidental chemical release resulting in a fatality, serious injury, or substantial property damages.

The CSB issues safety recommendations based on data and analysis from investigations and safety
studies. The CSB advocates for these changes to prevent the likelihood or minimize the consequences of
accidental chemical releases.

More information about the CSB and CSB products can be accessed at www.csb.gov or obtained by
contacting:

U.S. Chemical Safety and Hazard Investigation Board

1750 Pennsylvania Ave. NW, Suite 910
Washington, DC 20006
(202) 261-7600

The CSB was created by the Clean Air Act Amendments of 1990, and the CSB was first funded and
commenced operations in 1998. The CSB is not an enforcement or regulatory body. No part of the
conclusions, findings, or recommendations of the Board relating to any accidental release or the
investigation thereof shall be admitted as evidence or used in any action or suit for damages arising out of
any matter mentioned in such report. 42 U.S.C. § 7412(r)(6)(G).

1
 Investigation Report

The July 27, 2021 chemical release at the LyondellBasell

La Porte Complex fatally injured two people:

Dusty Day and Shawn Kuhleman

2
 Investigation Report

CONTENTS
ABBREVIATIONS ................................................................................................................................... 4
EXECUTIVE SUMMARY ......................................................................................................................... 5
1 BACKGROUND .............................................................................................................................. 9
1.1 LYONDELLBASELL LA PORTE COMPLEX ...................................................................................................... 9
1.2 ACETIC ACID PRODUCTION PROCESS AND CHEMICAL HAZARDS..................................................................... 9
1.3 TURN2 SPECIALTY COMPANIES .............................................................................................................. 10
1.4 DESCRIPTION OF SURROUNDING AREA.................................................................................................... 10
2 INCIDENT DESCRIPTION .............................................................................................................. 12
3 SAFETY ISSUES ............................................................................................................................ 17
3.1 VALVE DESIGN TO PREVENT HUMAN ERROR............................................................................................ 17
3.1.1 INCIDENTS IN WHICH PRESSURE-RETAINING COMPONENTS WERE INADVERTENTLY REMOVED FROM PLUG
VALVES .................................................................................................................................................17
3.1.2 NEED FOR SAFER DESIGN OF PLUG VALVES ......................................................................................21
3.2 PROVIDING WORKERS WITH CONDITIONS, PROCEDURES, AND TRAINING TO SAFELY CONDUCT WORK.............. 24
4 CONCLUSIONS ............................................................................................................................ 27
4.1 FINDINGS ........................................................................................................................................... 27
4.2 CAUSE ............................................................................................................................................... 27
5 RECOMMENDATIONS.................................................................................................................. 28
5.1 LYONDELLBASELL ................................................................................................................................ 28
5.2 TURN2 SPECIALTY COMPANIES .............................................................................................................. 28
5.3 AMERICAN SOCIETY OF MECHANICAL ENGINEERS ..................................................................................... 28
5.4 AMERICAN PETROLEUM INSTITUTE ......................................................................................................... 29
5.5 VALVE MANUFACTURERS ASSOCIATION OF AMERICA TECHNICAL COMMITTEE .............................................. 29
6 KEY LESSONS FOR THE INDUSTRY ................................................................................................ 31
7 REFERENCES .............................................................................................................................. 32
APPENDIX A—CAUSAL ANALYSIS (ACCIMAP) ...................................................................................... 34
APPENDIX B—DESCRIPTION OF SURROUNDING AREA ........................................................................ 35

3
 Investigation Report

Abbreviations
API American Petroleum Institute

ASME American Society of Mechanical Engineers

BEM butyl ethyl magnesium

CCPS Center for Chemical Process Safety

CSB U.S. Chemical Safety and Hazard Investigation Board

EPA Environmental Protection Agency

NIOSH National Institute for Occupational Safety and Health

OSHA Occupational Safety and Health Administration

PSM Process Safety Management

RMP Risk Management Program

SDS safety data sheet

VMA Valve Manufacturers Association of America

4
 Investigation Report

EXECUTIVE SUMMARY
On July 27, 2021, three contract workers employed by Turn2 Specialty Companies (Turn2) at the
LyondellBasell La Porte Complex in La Porte, Texas, were working to remove an actuator from a plug valve in
the site’s acetic acid unit.a The actuator was being removed so that the valve could be used as an energy
isolation device for a pipe spool repair job. The workers, however, inadvertently removed pressure-retaining
components of the valve while attempting to remove the actuator, and the pressure ejected the plug from the
valve body. Approximately 164,000 pounds of acetic acid mixture erupted from the open equipment, and all
three contract workers were sprayed with the releasing acetic acid mixture. Two of the workers were fatally
injured by chemical burns and toxic inhalation injuries from exposure to acetic acid and methyl iodide.
Additionally, the third Turn2 worker and a LyondellBasell responder were seriously injured. LyondellBasell
transported 29 other personnel to medical facilities for further evaluation and treatment. LyondellBasell’s
property damage resulting from the incident, including loss of use, was estimated to be $40 million.

SAFETY ISSUES
The CSB’s investigation identified the safety issues below.

• Valve Design to Prevent Human Error. There have been past incidents in which chemical industry
workers inadvertently removed pressure-retaining components from a plug valve installed in pressurized
service while attempting to remove an actuator. The CSB has identified four other similar plug valve
incidents, all of which resulted in fatalities or serious injuries. The recurrence of incidents in which
workers have inadvertently removed pressure-retaining components from plug valves points to the need
to further re-design these valves such that it would be difficult to remove pressure-retaining components
from plug valves while attempting to remove actuating equipment. (Section 3.1)

• Providing Workers with Conditions, Procedures, and Training to Safely Conduct Work. The CSB
found that LyondellBasell and Turn2 considered the actuator removal job to be a simple task and that
LyondellBasell did not provide the work crew with a procedure detailing how to remove the actuator
from the plug valve. In addition, neither LyondellBasell nor Turn2 trained the work crew on the steps
necessary to remove the actuator, and LyondellBasell did not adequately assess the potential risk of
exposing the contract crew to hazardous chemicals during the actuator removal in light of historical
incidents in the industry in which workers have inadvertently removed pressure-retaining components
from plug valves installed in pressurized service. (Section 3.2)

CAUSE
The CSB determined that the cause of the incident was the inadvertent removal of pressure-retaining
components from a plug valve in pressurized service while workers were removing the valve’s actuator.
Contributing to the incident was a plug valve design that did not include sufficient design features to prevent the

a
LyondellBasell used this plug valve to shut off (or turn on) the flow of methanol into an adjacent reactor. A pneumatic actuator
provided the necessary torque to operate the valve.

5
 Investigation Report

inadvertent removal of pressure-retaining valve components, the lack of procedures to conduct the actuator
removal work, and the lack of training for the workers conducting the work.

RECOMMENDATIONS
To LyondellBasell

2021-05-I-TX-R1

Update LyondellBasell policy documents to require that procedures are developed for properly removing
actuating equipment from plug valves. Require that the procedures clearly identify which non-pressure-retaining
components are safe to remove and pressure-retaining components that shall not be removed, as well as ensure
LyondellBasell personnel are trained on these procedures. Ensure that hazardous energy is controlled when
performing these procedures, as required by 29 C.F.R. 1910.147. Require in the policy document that risk
assessments for process safety are conducted before the actuating equipment removal work is authorized. Ensure
that sufficient procedures and safeguards are in place to prevent worker exposure to process fluid.

2021-05-I-TX-R2

Update LyondellBasell policy documents to require that LyondellBasell competenta employee(s), as defined by
29 C.F.R. 1926.32(f), verify that contractors are competent, adequately trained, and qualified to perform the
required work. To make this determination and to ensure work on process equipment is conducted in a safe
manner, LyondellBasell competent employees may be required to oversee the work conducted by contractors on
the process equipment. In the updated policy documents, include requirements to ensure that contract employees
are informed of relevant process hazards and relevant details about the process equipment and are provided with
equipment-specific procedures necessary to safely conduct their work.

To Turn2 Specialty Companies

2021-05-I-TX-R3

Update Turn2 policy documents to require that Turn2 employees are provided with written, detailed procedures
for safely conducting work on process equipment and are trained on the procedures before the work is
authorized to be performed.

a
OSHA defines a “competent person” as “one who is capable of identifying existing and predictable hazards in the surroundings or
working conditions which are unsanitary, hazardous, or dangerous to employees, and who has authorization to take prompt corrective
measures to eliminate them.”

6
 Investigation Report

To American Society of Mechanical Engineers

2021-05-I-TX-R4

Revise American Society of Mechanical Engineers (ASME) Standard B16.34 Valves—Flanged, Threaded, and
Welding End as follows:

a. For existing plug valves, require facilities to clearly mark all pressure-retaining components (for
example, with paint, accompanying warning signs, etc.). Work with American Petroleum Institute (API)
and the Valve Manufacturers Association of America (VMA) to ensure a consistent methodology is
specified across both API and ASME standards.

b. Require that new plug valves be designed, consistent with Prevention through Design principles, to
prevent the inadvertent removal of pressure-retaining components when removing the actuator or
gearbox. Evaluate past plug valve incidents, and the associated plug valve designs involved in those
incidents, when formulating a new plug valve design. Work with API and VMA to ensure a consistent
methodology is specified across both API and ASME standards.

To American Petroleum Institute

2021-05-I-TX-R5

Revise API Standard 599 Metal Plug Valves—Flanged, Threaded, and Welding Ends as follows:

a. State that there have been multiple incidents in which workers have inadvertently removed pressure-
retaining components from plug valves while workers were attempting to remove the valve’s actuator or
gearbox.

b. Recommend that facilities using plug valves establish written procedures detailing the correct way to
remove the plug valve actuator or gearbox for each specific plug valve design at the facility.

c. For existing plug valves, require facilities to clearly mark all pressure-retaining components (for
example, with paint, accompanying warning signs, etc.). Work with ASME and VMA to ensure a
consistent methodology is specified across both API and ASME standards.

d. Require that new plug valves be designed, consistent with Prevention through Design principles, to
prevent the inadvertent removal of pressure-retaining components when removing the actuator or
gearbox. Evaluate past plug valve incidents, and the associated plug valve designs involved in those
incidents, when formulating a new plug valve design. Work with ASME and VMA to ensure a
consistent methodology is specified across both API and ASME standards.

7
 Investigation Report

To Valve Manufacturers Association of America Technical Committee

2021-05-I-TX-R6

Work with ASME and API and develop a white paper to the Valve Manufacturers Association of America
addressing the issue of plug valve design with a focus on the following:

a. Recommend as an industry good practice that facilities using plug valves establish written procedures
detailing the correct way to remove the plug valve actuator or gearbox for each specific plug valve
design.

b. For existing plug valves, recommend as an industry good practice for facilities to clearly mark all
pressure-retaining components (for example, with paint, accompanying warning signs, etc.). Work with
ASME and API to ensure a consistent methodology is specified to the industry.

c. Recommend new plug valves be designed, consistent with Prevention through Design principles, to
prevent the inadvertent removal of pressure-retaining components when removing the actuator or
gearbox. Evaluate past plug valve incidents, and the associated plug valve designs involved in those
incidents, when formulating a new plug valve design recommendation. Work with ASME and API to
ensure a consistent design is recommended to the industry.

8
 Investigation Report

1 BACKGROUND
1.1 LYONDELLBASELL LA PORTE COMPLEX
LyondellBasell is a plastics, chemicals, and refining company that owns and operates facilities located in 32
countries, including the United States [1]. The LyondellBasell La Porte complex, located in La Porte, Texas, is
the world’s third largest producer of acetic acid, a flavor enhancer and food preservative. The LyondellBasell La
Porte complex spans approximately 550 acres and employs roughly 675 employees and contractors. The acetic
acid unit at the LyondellBasell complex is covered by the Occupational Safety and Health Administration
(OSHA) Process Safety Management (PSM) regulation.a The acetic acid unit is not covered by the
Environmental Protection Agency’s (EPA’s) Risk Management Program (RMP).b

1.2 ACETIC ACID PRODUCTION PROCESS AND CHEMICAL HAZARDS

The production of acetic acid at the LyondellBasell La Porte Complex involves reacting methanol with carbon
monoxide in the presence of a catalyst and catalyst additives, one of which is methyl iodide (Figure 1).

Figure 1. Simplified block flow diagram of the acetic acid reaction process. (Credit: CSB)

Acetic acidc is a clear, colorless, corrosive liquid with a characteristic strong, acrid, vinegar odor. Acetic acid
has a boiling point of 244 °F and a relative vapor density of 2.1, which means that its vapors are heavier than air
and will collect along the ground or in low-lying areas when exposed to atmospheric conditions.d
LyondellBasell’s SDS for acetic acid indicates that the corrosive liquid may be harmful if swallowed or inhaled
into airways, and it may cause severe skin burns and eye damage upon exposure.

Methyl iodide is a colorless, noncombustible liquid with a pungent, ether-like odor [2]. Methyl iodide has a
boiling point of 109 °F [2] and a relative vapor density of 4.9. The National Institute for Occupational Safety

a
The acetic acid manufacturing process is covered under OSHA’s PSM regulation because the process contains methyl iodide in excess
of 7,500 pounds [27].
b
The acetic acid unit is not covered by the EPA RMP because it does not contain any regulated chemicals under 40 CFR Part 68 in
excess of the threshold quantity.
c
The information contained in this section references glacial acetic acid, 50%-80%, and was determined using LyondellBasell’s safety
data sheet (SDS).
d
Acetic acid has a vapor density of 2.1, compared with that of air, which is 1.0.

9
 Investigation Report

and Health (NIOSH) states that methyl iodide is a potential occupational carcinogen, and that exposure can
cause eye, skin, and respiratory system irritation. [3].

At the time of the incident, the acetic acid reactor contained approximately 164,000 pounds of a liquid mixture.
The liquid mixture contained over 100,000 pounds of glacial acetic acid and over 27,000 pounds of methyl
iodide. The remaining contents consisted of water and other additives. When the release occurred, the
temperature of the contents was at 238 °F, indicating that the bulk of the acetic acid likely remained in its liquid
state while the bulk of the methyl iodide likely vaporized upon release into the atmosphere.

1.3 TURN2 SPECIALTY COMPANIES

Turn2 Specialty Companies (Turn2) is a turnarounda services provider to the refining, petrochemical, and power
industries that is headquartered in Baytown, Texas [4]. LyondellBasell had a Master Field Services Agreement
with Turn2 for work that began in March 2019,b for which Turn2 provided general mechanical and maintenance
services for turnarounds and outages. In the weeks leading up to the incident, LyondellBasell assigned Turn2 to
conduct work on the furnaces in one of the site’s units, utilizing as many as 30 workers per day. This work
included unbolting and cutting tubes, removing the furnace tubes, and reinstalling via bolting or specialty
welding new tubes in the furnaces. In addition to the furnace work, Turn2 personnel also performed ancillary
maintenance tasks in other areas at the La Porte Complex.

1.4 DESCRIPTION OF SURROUNDING AREA

Figure 2 shows the LyondellBasell La Porte Complex and depicts the area within one, three, and five miles of
the facility boundary. Summarized demographic data for the approximately one-mile vicinity of the facility are
shown below in Table 1. There are over 6,000 people residing in over 2,000 housing units, most of which are
single units, within one mile of the LyondellBasell La Porte facility. Detailed demographic data are included in
Appendix B.

a
A turnaround can be defined as “a planned shutdown of an asset, process, or total plant to identify and repair major potential problems
in a timely manner to improve plant safety and efficiency [25].”
b
In March 2019, Turn2 was operating as Epic Specialty Companies LLC.

10
 Investigation Report

Figure 2. Overhead satellite image of the LyondellBasell La Porte complex

(blue) and the surrounding area. (Credit: Google Maps, annotated by CSB)

Table 1. Summarized demographic data for the approximately one-mile vicinity of the LyondellBasell La Porte
Complex. (Credit: Census Reporter)
Number
Per Capita Percent of
Population Race and Ethnicity Types of Housing Units
Income Povertya Housing
Units
White 70% Single Unit 94%
Hispanic 28% Mobile Home 6%
6,269 Two+ 1% $45,178b 10.8% 2,168
Asian 0.7 %
Black 0.3%

a
The “Percent Poverty” figure represents the number of persons below the poverty line in the city of La Porte, Texas [21].
b
Census Reporter reports that La Porte’s per capita income was $40,935 [21]. The Census Bureau reports that the overall per capita
income for the United States from 2017–2021 was $37,638 [22].

11
 Investigation Report

2 INCIDENT DESCRIPTION
On Saturday, July 24, 2021, an operations technician for the LyondellBasell acetic acid unit discovered a small
leak on methanol piping upstream of the unit’s acetic acid reactor. A subsequent inspection identified that the
leak originated in a weld within the methanol piping. Shortly after the leak was discovered, the shutdown of an
adjacent process unit required the acetic acid unit to also shut down acetic acid production. LyondellBasell
personnel decided to use the shutdown opportunity to remove and repair the leaking portion of the methanol
piping (Figure 3).

Figure 3. Post-incident photograph of the methanol leak location, the portion of the piping that
LyondellBasell planned to repair, and the location of the plug valve involved in the incident.
(Credit: CSB)

To isolate the piping, which contained methanol and acetic acid, LyondellBasell personnel chose to use the
valve located between the leaking piping and the nearby acetic acid reactor—a pneumatically actuated eight-
inch plug valve—as an isolation device (Figure 4). LyondellBasell’s Energy Isolation Procedure specified that

12
 Investigation Report

the only pneumatically actuated control valves that were deemed to be approved energy isolation devicesa were
those equipped with manual hand jacks, which could be physically closed and locked. LyondellBasell personnel
therefore decided that they would remove the actuator connected to the plug valve (including its coupler) so that
a pipe tee could be installed over the valve stem. The pipe tee would then have a chain passed through the
opening with the two ends of the chain being padlocked, thus meeting the requirements for having a physical
lock installed (Figure 5) according to their procedure. LyondellBasell directed its third-party contractor, Turn2,
to perform the actuator removal task. Turn2 had communicated to LyondellBasell that it had a night crew that
was qualified and available to remove the actuator.

At around 5:00 p.m. on July 27, 2021, the Turn2 superintendent and night foreman met with LyondellBasell
operations personnel at the acetic acid unit operations building to review the actuator removal task. The Turn2
superintendent, the Turn2 foreman, and a LyondellBasell operator then walked into the unit, and the operator
showed the two Turn2 personnel where the actuator to be removed was located. LyondellBasell did not have a
procedure detailing how to remove the actuator, and neither LyondellBasell nor Turn2 trained the Turn2
personnel on how to remove the actuator.

Figure 4. Plug valve involved in incident. Figure 5. Schematic showing LyondellBasell’s

(Credit: MRC Global) lockout plan for the plug valve. (Credit: CSB)

At around 6:45 p.m., LyondellBasell issued the work permit for the task, and a LyondellBasell operator told the
U.S. Chemical Safety and Hazard Investigation Board (CSB) that he walked with the Turn2 foreman and two
Turn2 pipefitters to the acetic acid unit and showed them the actuator they were to remove.b The LyondellBasell
operator then left the area, and the Turn2 foreman and two Turn2 pipefittersc began work to remove the plug

a
OSHA defines an “energy isolation device” as “a mechanical device that physically prevents the transmission or release of energy…
[26].”
b
A Turn2 worker disputes that the operator walked with the crew to the actuator before they began working to remove the actuator. The
CSB was unable to confirm which statement was accurate.
c
This work crew had been working on repairing heat exchanger tubes as welders or welder helpers. The CSB did not find documentation
indicating the work crew had experience installing, repairing, or removing valves or valve actuators. A Turn2 manager, however,
communicated that two members of the work crew had experience removing actuators.

13
 Investigation Report

valve actuator. At this time, the acetic acid reactor (located directly above the location where the contractors
were working) contained approximately 164,000 pounds of a 61.7% acetic acid mixture at a pressure of 130
pounds per square inch (psi) and a temperature of 238 °F. The Turn2 workers removed the insulation material
from the exterior of the plug valve, then began to remove the bracket mounting bolts located on the exterior of
the actuator mounting bracket (Figure 6A). Before removing all of the bracket mounting bolts, the Turn2
workers determined that they needed a socket wrench to remove the nuts shown in Figure 6B. The Turn2
foreman went to his truck to retrieve a socket wrench set, which would allow them to remove the nuts shown in
Figure 6B. The Turn2 employees did not know that removing the nuts shown in Figure 6B was not necessary to
remove the actuator;a nor did they know that the nuts were pressure-retaining, holding the valve cover in place.
Once the Turn2 foreman returned to the worksite, the Turn2 work crew removed all of the pressure-retaining
nuts shown in Figure 6B, not recognizing that they had compromised the pressure integrity of the valve. The
Turn2 crew then finished removing all of the bracket mounting bolts shown in Figure 6A.

After removing all of the bracket mounting bolts and inadvertently removing the pressure-retaining valve cover
nuts from the plug valve, the Turn2 work crew removed the actuator and the affixed actuator mounting bracket
from the plug valve and placed it on the deck grating (Figure 7). Once the actuator was removed, the Turn2
work crew noticed that the coupler was still seated in its designated slot on the top of the valve stem (Figure 6B
and 6C). The Turn2 workers attempted to slide the coupler off of the valve stem, but because it was too tight to
remove by hand, the Turn2 work crew decided to use a pry bar to try and remove it. While using the pry bar on
the coupler, the combination of forces from the pry bar and the process fluid pressure inside the plug valve
caused the unfastened valve cover and plug to eject from the plug valve body, and acetic acid rapidly released
from the open plug valve.

a
One of the workers explained his reasoning for removing the pressure-retaining nuts shown in Figure 6B. He told the CSB they had to
remove the interior fasteners because “…it’s all connected. As [the actuator] sits up there, it’s all connected to one another.” This
worker did not seem to understand that the interior fasteners were pressure-retaining and should not have been removed.

14
 Investigation Report

Figure 6. (A) Photo of the incident valve with the four actuator
mounting bolts highlighted; (B) Photo of exemplar valve pressure-
retaining nuts, and (C) Photo of exemplar valve with coupler removed.
(Credit: CSB)

15
 Investigation Report

Figure 7. Post-incident photo showing the actuator and the affixed mounting bracket positioned on deck
grating. (Credit: CSB)

According to recorded performance trend data for the acetic acid reactor, the liquid level in the reactor began to
decrease rapidly. The entire contents of the acetic acid reactor, roughly 164,000 pounds of acetic acid mixture at
238 °F, emptied from the reactor by way of the open, unplugged valve. All three Turn2 workers were sprayed
by the releasing acetic acid mixture. The Turn2 foreman and one pipefitter were fatally injured from chemical
burns and inhalation of the released acetic acid and methyl iodide, and the second pipefitter was seriously
injured from acid exposure. LyondellBasell transported 29 personnel, who were working in an adjacent unit at
the time of the incident, to medical facilities for further evaluation and treatment.a

a
The CSB is unaware of any injuries reported from these personnel.

16
 Investigation Report

3 SAFETY ISSUES
KEY LESSON
The following sections discuss the safety issues contributing to the
Multiple incidents have
incident:
occurred in the chemical
industry where employees
• Valve Design to Prevent Human Error
have inadvertently removed
• Providing Workers with Conditions, Procedures, and Training to pressure-retaining bolts from
Safely Conduct Work plug valves when attempting
to remove actuating
equipment. This has led to
3.1 VALVE DESIGN TO PREVENT HUMAN ERROR plug valves coming apart,
There have been at least five incidents (including the LyondellBasell releases of hazardous
incident) in which workers inadvertently removed pressure-retaining materials, and serious injuries
components from plug valves while they were attempting to remove and worker fatalities.
connected actuating equipment, as described below.a

3.1.1 INCIDENTS IN WHICH PRESSURE-RETAINING

COMPONENTS WERE INADVERTENTLY
REMOVED FROM PLUG VALVES

3.1.1.1 Puebla, Mexico, 1977 Incident

On June 19, 1977, in Puebla, Mexico, a maintenance worker incorrectly
removed an actuator from a plug valve that was situated on a liquid
discharge line beneath a vinyl chloride storage tank. The worker
mistakenly removed pressure-retaining bolts instead of the bolts that
connected the actuator to the adaptor (Figure 8). The plug, sleeve, and
valve cover then blew out under the system pressure and caused a
massive release of vinyl chloride. The vinyl chloride formed a vapor
cloud that eventually ignited, and led to additional subsequent
explosions, causing severe damage to the site. The incident fatally injured
one person and severely injured four other people. Nearly 90 additional
people suffered burns from the intense thermal radiation from one of the
explosions [5].

a
The CSB is aware of other incidents in which workers inadvertently removed pressure-retaining components from other types of valves
(e.g., ball valves) in pressurized service, resulting in hazardous process fluid releases. However, it appears that most incidents involving
the inadvertent removal of pressure-retaining components occur when working on plug valves.

17
 Investigation Report

Figure 8. Series of schematics showing the inadvertently dismantled valve in the Puebla, Mexico, incident: (1)
Assembled plug valve and actuator; (2) Correct unbolting locations; (3) Actual unbolting location; (4) Plug
ejected from valve. (Credit: Loss Prevention Bulletin 100 [5])

3.1.1.2 U.S. Amoco Plant 1980 Incident

In October 1980, for added safety during a cleaning operation of piping, procedures required mechanics to
remove the actuator for a plug valve that was to be used to isolate a polypropylene reactor, so that the valve
would not be inadvertently opened during the cleaning operation. Two employees removed the pressure-
retaining bolts holding the plug valve cover in place instead of the bolts holding the actuator in place. The 150-
psi system pressure blew out the plug, causing the release of hydrocarbons and polymer. The resulting vapor
cloud ignited, causing severe damage to the facility. Six employees were fatally injured [6, pp. 189-190] [7].

3.1.1.3 AkzoNobel Polymer Chemicals La Porte, Texas, 2013 Incident

On March 4, 2013, a contract worker was troubleshooting four valve actuation systems on a vessel containing
butyl ethyl magnesium (BEM) that were not operating as designed. On the first three systems, the worker
resolved the issues by replacing the fittings and air lines. Replacing these components on the fourth system,
however, did not work. The worker, who was in training to be a certified instrumentation technician, first
attempted to remove the actuator from its mounting bracket. When this attempt was unsuccessful, the worker
removed the actuator mounting bolts, which also held the plug valve cover in place. This resulted in a release of
BEM through the valve body opening, exposing the worker to BEM and causing burn injuries. The BEM, which
is pyrophoric,a also ignited following the loss of containment. The company’s internal investigation determined

a
A pyrophoric substance ignites when it is exposed to air.

18
 Investigation Report

that the causal factors included, among other things, the absence of qualified supervision and the absence of a
job-specific procedure.

3.1.1.4 ExxonMobil Baton Rouge Refinery 2016 Incident

On November 22, 2016, during the removal of an inoperable gearbox on a plug valve, the operator performing
the activity removed critical pressure-retaining bolts securing the pressure-retaining top-cap of the valve instead
of bolts that secured only the gearbox (Figure 9). When the operator then attempted to open the plug valve with
a pipe wrench, the valve came apart and released isobutane into the unit, forming a flammable vapor cloud. The
vapor cloud ignited and severely burned four workers. The CSB investigated this incident and published a
Safety Bulletin titled Key Lessons from the ExxonMobil Baton Rouge Refinery Isobutane Release and Fire [8].a

a
Link to report: https://www.csb.gov/file.aspx?DocumentId=6045

19
 Investigation Report

Figure 9. Depiction of the gearbox removal on the day of the ExxonMobil Baton Rouge 2016 incident (left),
and depiction of how the gearbox should have been removed (right). (Credit: CSB [8])

20
 Investigation Report

3.1.1.5 LyondellBasell 2021 Incident

KEY LESSON
This incident is the subject of this report. Workers inadvertently removed
pressure-retaining components from a plug valve while attempting to To prevent future incidents in
remove the valve’s actuator. which workers inadvertently
remove pressure-retaining
The CSB notes that the design of the plug valve involved in the
components from plug valves
LyondellBasell incident was of a newer design recommended by the
while attempting to remove
American Petroleum Institute (API) Standard 599 Metal Plug Valves—
actuating equipment, facilities
Flanged, Threaded, and Welding Ends that would allow an actuator to be
should clearly mark or
mounted or removed without affecting the pressure retention of the valve.
identify pressure-retaining
API 599 states:
bolts on existing plug valves,
• “The [plug valve] design shall ensure the stem cannot be ejected for example through color
from the valve by removal of … actuator mounting hardware [9, coding techniques and/or
p. 6].” warning labels or signs.

• “Valves supplied with the capability of mounting actuators or

gear operators shall be capable of doing so without removal of
any pressure-containing parts (e.g. body bolts, bonnet/cover
bolts, flange bolts, packing gland bolts, packing retaining stem
nut, etc.) [9, p. 8].”

This newer design, however, did not prevent workers from inadvertently
removing pressure retaining components while removing the actuator.

3.1.2 NEED FOR SAFER DESIGN OF PLUG VALVES

The recurrence of incidents in which pressure-retaining components have been inadvertently removed from plug
valves points to the need to further re-design these valves to prevent workers from accidentally removing
pressure-retaining components while attempting to remove the actuating equipment. Listed below are methods
various entities have identified to prevent people from removing certain equipment components or using
incorrect tools on equipment:

• In his book An Engineer’s View of Human Error (Third edition), in which the theme of the book is “Try
to change situations, not people,” Trevor Kletz states, “A hardware solution is possible [to prevent
inadvertent removal of pressure-retaining components of valves]. Bolts which can safely be undone
when the plant is up to pressure could be painted green; others could be painted red.a A similar
suggestion is to use bolts with recessed heads and fill the heads with lead if the bolts should not be
undone when the plant is up to pressure [10, p. 175].”

a
One of the workers at the LyondellBasell facility mentioned to the CSB, “Nothing was marked. None of the bolts were labeled
‘remove’ [or] ‘don’t remove.’”

21
 Investigation Report

• Many modern cars are equipped with locking wheel nuts to deter wheel theft. These locking wheel nuts
come with a matching key that must be used to remove the wheel nut [11] [12].

• Valves manufactured by the company Descotea include a sign on the handwheel that reads “Do Not Use
a Wrench” (Figure 10) [13]. Similar to this approach, plug valves could be equipped with recessed bolts
and covered with an appropriate sign warning that those bolts should not be removed in pressurized
service.

Figure 10. Photograph of a Descote valve’s warning sign to not use a

wrench on the valve. (Credit: Steven Levy Enterprises [14])

Considering the recurrence of these incidents, a concept known as “Prevention through Design,” or PtD, should
be employed when designing new plug valves to prevent the inadvertent removal of pressure-retaining
components on plug valves. NIOSH defines PtD as “…anticipating and designing out or eliminating safety and
health hazards in facilities, work methods, and operations, processes, equipment, tools, products, new
technologies, and the organization of work” [15].

The Valve Manufacturers Association of America (VMA) is an industry trade association whose mission is, in
part, to increase knowledge. The VMA strives to “provide industry expertise...” as one of its strategic priorities.
The VMA has a Technical Committee that “identifies, discusses and advises VMA on key valve industry
technical issues.” Part of its function is to identify good practices and develop standards affecting the industry.
American Society of Mechanical Engineers (ASME) Standard B16.34 Valves—Flanged, Threaded, and Welding
End specifies design requirements for valves, including plug valves, and API Standard 599 Metal Plug Valves—
Flanged, Threaded, and Welding Ends specifies design requirements specifically for plug valves. These
standards recommend that any mounting bolts or devices do not impact the pressure retaining components.

a
The Descote valve pictured in this report was not involved in the incident. The CSB selected this sign simply as an example of how a
visual system can be used to enhance safety.

22
 Investigation Report

Neither standard contains requirements or recommendations to distinguish pressure-retaining components from

those that are not pressure-retaining.

The CSB concludes that had the LyondellBasell plug valve pressure-retaining bolts been clearly identified (such
as through paint markings or a warning label or sign), the work crew might have removed only the bolts
securing the actuator to the plug valve, which would have prevented the incident. The CSB also concludes that
to prevent future incidents in which workers inadvertently remove pressure-retaining components from plug
valves while attempting to remove actuators and gearboxes, prevailing valve standards should be revised to
require that pressure-retaining components on existing valves are clearly marked, and that new plug valves be
designed to prevent the inadvertent removal of pressure-retaining components while attempting to remove the
actuating equipment. The CSB notes that after the incident, LyondellBasell installed tamper-resistant
mechanisms and tags on the valve cover fasteners of actuated plug valves within the unit to help prevent the
inadvertent removal of pressure-retaining components while the valves are in service (Figure 11).

Figure 11. Example of tamper-resistant mechanism incorporated by LyondellBasell. (Credit: CSB)

The CSB recommends that ASME and API, working with the VMA, revise their plug valve design standards to
require facilities to clearly mark all existing plug valve pressure-retaining components (for example, with paint
and accompanying warning labels or signs), and to require that new plug valves be designed, consistent with
Prevention through Design principles, to prevent the inadvertent removal of pressure-retaining components
when removing the actuator or gearbox.

23
 Investigation Report

3.2 PROVIDING WORKERS WITH CONDITIONS, PROCEDURES, AND TRAINING TO

SAFELY CONDUCT WORK
As outlined above, the same incidenta has been repeated at least five
times: workers intended to remove valve actuating equipment from a KEY LESSON
plug valve, the workers inadvertently removed pressure-retaining bolts,
the plug valve came apart, and hazardous process material was released, Facilities with plug valves
resulting in fatalities and serious injuries. In addition to demonstrating should develop formal
the need for plug valve design and marking improvements (discussed procedures for the removal of
above), these incidents also reveal the need for improved process safety plug valve actuating
management systems at facilities with these types of valves. Process equipment that require (1) a
safety author Roy E. Sanders laid out the following questions in his risk assessment of all plug
1996 article discussing an inadvertent valve disassembly: valve actuator removal work
to ensure sufficient
• Is the risk too high to [remove actuators] while the [equipment
procedures and safeguards are
is] full of a highly [hazardous] liquid?
in place to prevent worker
• Did written procedures exist detailing this job and its exposure to process fluid, (2)
precautions? written procedures detailing
actuator removal steps for the
• Were maintenance mechanics trained in the procedures [16]? specific valve design, and (3)
workers to be trained on the
Indeed, robust process safety management systems requiring risk procedure before conducting
analyses, detailed written procedures, and training on those procedures the actuator removal work.
could have prevented all five of the incidents discussed in this report.
Below, the conditions at LyondellBasell relating to each of the above
questions are discussed.

Is the risk too high to remove actuators while the equipment is full of a
highly hazardous liquid?

At the time of the incident, the acetic acid reactor located directly above
the plug valve contained approximately 164,000 pounds of a 61.7%
acetic acid mixture at a gauge pressure of 130 pounds per square inch
(psig) and 238 °F. The acetic acid mixture was flammable and could
cause severe skin burns and eye damage [17]., LyondellBasell personnel
did not consider the option of de-inventorying the reactor and connected
piping (or otherwise isolating the valve from hazardous energy) before
the actuator removal work could be authorized, as the planned actuator
removal should not have involved opening the process equipment.

The CSB concludes that in light of the repeated incidents in which

workers inadvertently removed pressure-retaining valve components

a
The CSB notes that the design of the plug valves involved in the incidents differed.

24
 Investigation Report

while working to remove actuating equipment, companies should thoroughly assess the risk involved in all plug
valve actuator removal work to ensure that sufficient procedures and safeguards are in place to prevent worker
exposure to process fluid. At some facilities, this risk assessment may determine that depressurizing and de-
inventorying equipment is required before removing plug valve actuating equipment. The CSB recommends that
LyondellBasell conduct risk assessments for process safety of plug valve actuator removal work before the work
is authorized.

Do written procedures exist detailing the job and its precautions?

LyondellBasell did not provide the work crew with a procedure or instructions on how to remove the actuator
from the plug valve. The OSHA PSM Standard requires that “[t]he employer shall establish and implement
written procedures to maintain the on-going integrity of process equipment.”a In addition, the Center for
Chemical Process Safety (CCPS) book Guidelines for Writing Effective Operating and Maintenance Procedures
states, “Procedures should identify the hazards presented by the process. Procedures should also state
precautions necessary to prevent accidental chemical release, exposure, and injury [18, p. 18].”

The CSB also found that both LyondellBasell and Turn2 personnel perceived the actuator removal to be a
simple task with minimal risks. In hindsight, when asked if they had a written procedure for the task, one Turn2
worker stated, “…not at all. I think that would have been pretty helpful.” The CSB concludes that
LyondellBasell failed to provide the Turn2 work crew with a written procedure and allowed the work to be done
without LyondellBasell’s oversight because of the perceived simplicity of the actuator removal, as well as
representations made by Turn2 that its work crew could perform the task. Had LyondellBasell provided a
procedure to the Turn2 work crew that detailed the bolts to be removed for the actuator removal work and
warned against removing the pressure-retaining bolts, the incident could have been prevented. The CSB
recommends that LyondellBasell update its policy documents to require that procedures are developed for
removing actuating equipment from plug valves. The CSB also recommends that Turn2 update its policy
documents to require that Turn2 employees are provided with written, detailed procedures for safely conducting
work on process equipment.

a
29 C.F.R. 1910.119 (j) (2)

25
 Investigation Report

Were maintenance mechanics trained in the procedures?

LyondellBasell selected a contractor, Turn2, to conduct the actuator KEY LESSON

removal work. When the Turn2 superintendent and Turn2 foreman
arrived at the unit to review the task, a LyondellBasell operator showed When contractors are
the Turn2 superintendent and Turn2 foreman where the actuator to be conducting work on or near
removed was located, and Turn2 proceeded with the actuator removal plant equipment containing
work that evening. The OSHA PSM Standard requires that “[t]he contract hazardous materials, it is
employer shall assure that each contract employee is trained in the work critical for the operating
practices necessary to safely perform his/her job.” The CSB concludes company to oversee the
that neither LyondellBasell nor Turn2 trained the Turn2 work crew on contractor work and ensure
the steps necessary to remove the actuator. Had the Turn2 work crew that it is conducted in a safe
been trained on which bolts to remove to safely remove the actuator from manner.
the plug valve, the incident might not have occurred. The CSB
recommends that Turn2 update its policy documents to require that Turn2
employees are trained on procedures for safely conducting work on
process equipment before the work is authorized to be performed.

Contractors may be less familiar with plant equipment than in-house staff. Further, the use of contractors often
“involves a loss of control over the execution of work” by the company [19, p. 1382]. When contractors are
conducting work on or near plant equipment containing hazardous materials, it is critical for the operating
company to ensure the contractors are competent and qualified to perform the required work, which could
include company competent employees overseeing that the contractor work is conducted in a safe manner. As
stated by the Center for Chemical Process Safety (CCPS) in its book Guidelines for Risk Based Process Safety,
“While contractors have a responsibility to monitor the action of their employees and to enforce the safety
performance requirements, the ultimate responsibility for ensuring the safety of its facility rests with the
company [20, p. 376].” The CSB concludes that LyondellBasell did not sufficiently determine that the
contractors performing the work were competent, adequately trained, or qualified to perform the actuator
removal, and LyondellBasell did not provide sufficient oversight of the actuator removal task. Had
LyondellBasell ensured the contractors were competent, adequately trained, and qualified to perform the
actuator removal or provided oversight by a competent LyondellBasell employee, the incident might not have
occurred. The CSB recommends to LyondellBasell to update its policy documents to require that LyondellBasell
competenta employee(s), as defined by 29 C.F.R. 1926.32(f), verify that Contractors are competent, adequately
trained, and qualified to perform the required work. To make this determination and to ensure that work on
process equipment is conducted in a safe manner, LyondellBasell competent employees may be required to
oversee the work conducted by contractors on the process equipment. The CSB also recommends that
LyondellBasell ensure that contract employees are informed of relevant process hazards and relevant details
about the process equipment and are provided with equipment-specific procedures necessary to safely conduct
their work.

a
OSHA defines a “competent person” as “one who is capable of identifying existing and predictable hazards in the surroundings or
working conditions which are unsanitary, hazardous, or dangerous to employees, and who has authorization to take prompt corrective
measures to eliminate them.”

26
 Investigation Report

4 CONCLUSIONS
4.1 FINDINGS
Valve Design to Prevent Human Error

1. Had the LyondellBasell plug valve pressure-retaining bolts been clearly identified (such as through paint
markings or a warning label or sign), the work crew might have removed only the bolts securing the actuator
to the plug valve, which would have prevented the incident.

2. To prevent future incidents in which workers inadvertently remove pressure-retaining components from
plug valves while attempting to remove actuators and gearboxes, prevailing valve standards should be
revised to require that pressure-retaining components on existing valves are clearly marked, and that new
plug valves be designed to prevent the inadvertent removal of pressure-retaining components while
attempting to remove the actuating equipment.

Providing Workers with Conditions, Procedures, and Training to Safely Conduct Work

3. In light of the repeated incidents in which workers inadvertently removed pressure-retaining valve
components while working to remove actuating equipment, companies should thoroughly assess the risk
involved in all plug valve actuator removal work to ensure that sufficient procedures and safeguards are in
place to prevent worker exposure to process fluid. At some facilities, this risk assessment may determine
that depressurizing and de-inventorying equipment is required before removing plug valve actuating
equipment.

4. LyondellBasell failed to provide the Turn2 work crew with a written procedure and allowed the work to be
done without LyondellBasell’s oversight because of the perceived simplicity of the actuator removal, as well
as representations made by Turn2 that its work crew could perform the task. Had LyondellBasell provided a
procedure to the Turn2 work crew that detailed the bolts to be removed for the actuator removal work and
warned against removing the pressure-retaining bolts, the incident could have been prevented.

5. Neither LyondellBasell nor Turn2 trained the Turn2 work crew on the steps necessary to remove the
actuator. Had the Turn2 work crew been trained on which bolts to remove to safely remove the actuator
from the plug valve, the incident might not have occurred.

6. LyondellBasell did not sufficiently determine that the contractors performing the work were competent,
adequately trained, or qualified to perform the actuator removal, and LyondellBasell did not provide
sufficient oversight of the actuator removal task. Had LyondellBasell ensured the contractors were
competent, adequately trained, and qualified to perform the actuator removal or provided oversight by a
competent LyondellBasell employee, the incident might not have occurred.

4.2 CAUSE
The CSB determined that the cause of the incident was the inadvertent removal of pressure-retaining
components from a plug valve in pressurized service while workers were removing the valve’s actuator.

27
 Investigation Report

Contributing to the incident was a plug valve design that did not include sufficient design features to prevent the
inadvertent removal of pressure-retaining valve components, the lack of procedures to conduct the actuator
removal work, and the lack of training for the workers conducting the work.

5 RECOMMENDATIONS
To prevent future chemical incidents, and in the interest of driving chemical safety excellence to protect
communities, workers, and the environment, the CSB makes the following safety recommendations:

5.1 LYONDELLBASELL
2021-05-I-TX-R1

Update LyondellBasell policy documents to require that procedures are developed for properly removing
actuating equipment from plug valves. Require that the procedures clearly identify which non-pressure-retaining
components are safe to remove and pressure-retaining components that shall not be removed, as well as ensure
LyondellBasell personnel are trained on these procedures. Ensure that hazardous energy is controlled when
performing these procedures, as required by 29 C.F.R. 1910.147. Require in the policy document that risk
assessments for process safety are conducted before the actuating equipment removal work is authorized. Ensure
that sufficient procedures and safeguards are in place to prevent worker exposure to process fluid.

2021-05-I-TX-R2

Update LyondellBasell policy documents to require that LyondellBasell competent employee(s), as defined by
29 C.F.R. 1926.32(f), verify that contractors are competent, adequately trained, and qualified to perform the
required work. To make this determination and to ensure work on process equipment is conducted in a safe
manner, LyondellBasell competent employees may be required to oversee the work conducted by contractors on
the process equipment. In the updated policy documents, include requirements to ensure that contract employees
are informed of relevant process hazards and relevant details about the process equipment and are provided with
equipment-specific procedures necessary to safely conduct their work.

5.2 TURN2 SPECIALTY COMPANIES

2021-05-I-TX-R3

Update Turn2 policy documents to require that Turn2 employees are provided with written, detailed procedures
for safely conducting work on process equipment and are trained on the procedures before the work is
authorized to be performed.

5.3 AMERICAN SOCIETY OF MECHANICAL ENGINEERS

2021-05-I-TX-R4

28
 Investigation Report

Revise American Society of Mechanical Engineers (ASME) Standard B16.34 Valves—Flanged, Threaded, and
Welding End as follows:

a. For existing plug valves, require facilities to clearly mark all pressure-retaining components (for
example, with paint, accompanying warning signs, etc.). Work with American Petroleum Institute (API)
and the Valve Manufacturers Association of America (VMA) to ensure a consistent methodology is
specified across both API and ASME standards.

b. Require that new plug valves be designed, consistent with Prevention through Design principles, to
prevent the inadvertent removal of pressure-retaining components when removing the actuator or
gearbox. Evaluate past plug valve incidents, and the associated plug valve designs involved in those
incidents, when formulating a new plug valve design. Work with API and VMA to ensure a consistent
methodology is specified across both API and ASME standards.

5.4 AMERICAN PETROLEUM INSTITUTE

2021-05-I-TX-R5

Revise API Standard 599 Metal Plug Valves—Flanged, Threaded, and Welding Ends as follows:

a. State that there have been multiple incidents in which workers have inadvertently removed pressure-
retaining components from plug valves while workers were attempting to remove the valve’s actuator or
gearbox.

b. Recommend that facilities using plug valves establish written procedures detailing the correct way to
remove the plug valve actuator or gearbox for each specific plug valve design at the facility.

c. For existing plug valves, require facilities to clearly mark all pressure-retaining components (for
example, with paint, accompanying warning signs, etc.). Work with ASME and VMA to ensure a
consistent methodology is specified across both API and ASME standards.

d. Require that new plug valves be designed, consistent with Prevention through Design principles, to
prevent the inadvertent removal of pressure-retaining components when removing the actuator or
gearbox. Evaluate past plug valve incidents, and the associated plug valve designs involved in those
incidents, when formulating a new plug valve design. Work with ASME and VMA to ensure a
consistent methodology is specified across both API and ASME standards.

5.5 VALVE MANUFACTURERS ASSOCIATION OF AMERICA TECHNICAL COMMITTEE

2021-05-I-TX-R6

Work with ASME and API and develop a white paper to the Valve Manufacturers Association of America
addressing the issue of plug valve design with a focus on the following:

a. Recommend as an industry good practice that facilities using plug valves establish written procedures
detailing the correct way to remove the plug valve actuator or gearbox for each specific plug valve
design.
29
 Investigation Report

b. For existing plug valves, recommend as an industry good practice for facilities to clearly mark all
pressure-retaining components (for example, with paint, accompanying warning signs, etc.). Work with
ASME and API to ensure a consistent methodology is specified to the industry.

c. Recommend new plug valves be designed, consistent with Prevention through Design principles, to
prevent the inadvertent removal of pressure-retaining components when removing the actuator or
gearbox. Evaluate past plug valve incidents, and the associated plug valve designs involved in those
incidents, when formulating a new plug valve design recommendation. Work with ASME and API to
ensure a consistent design is recommended to the industry.

30
 Investigation Report

6 Key Lessons for the Industry

To prevent future chemical incidents, and in the interest of driving chemical safety excellence to protect
communities, workers, and the environment, the CSB urges companies to review these key lessons:

1. Multiple incidents have occurred in the chemical industry where employees have inadvertently removed
pressure-retaining bolts from plug valves when attempting to remove actuating equipment. This has led to
plug valves coming apart, releases of hazardous materials, and serious injuries and worker fatalities.

2. To prevent future incidents in which workers inadvertently remove pressure-retaining components from
plug valves while attempting to remove actuating equipment, facilities should clearly mark or identify
pressure-retaining bolts on existing plug valves, for example through color coding techniques and/or
warning labels or signs.

3. Facilities with plug valves should develop formal procedures for the removal of plug valve actuating
equipment that require (1) a risk assessment of all plug valve actuator removal work to ensure sufficient
procedures and safeguards are in place to prevent worker exposure to process fluid; (2) written procedures
detailing actuator removal steps for the specific valve design; and (3) workers to be trained on the procedure
before conducting the actuator removal work.

4. When contractors are conducting work on or near plant equipment containing hazardous materials, it is
critical for the operating company to oversee the contractor work and ensure that it is conducted in a safe
manner.

31
 Investigation Report

7 References

[1] LyondellBasell Industries Holdings, B.V., "LyondellBasell Around the World," LyondellBasell Industries Holdings, B.V., 2022.
[Online]. Available: https://www.lyondellbasell.com/en/utilities/locations/. [Accessed 3 May 2022].
[2] National Institute for Occupational Safety and Health (NIOSH), "Methyl Iodide," National Institute for Occupational Safety and
Health, 30 October 2019. [Online]. Available: https://www.cdc.gov/niosh/npg/npgd0420.html. [Accessed 23 March 2023].
[3] National Institute for Occupational Safety and Health (NIOSH), "Table of IDLH Values - Methyl Iodide," National Institute for
Occupational Safety and Health (NIOSH), May 1994. [Online]. Available: https://www.cdc.gov/niosh/idlh/74884.html. [Accessed
23 March 2023].
[4] Turn2 Specialty Companies, "Industrial Services," Petropages, 2023. [Online]. Available: https://turn2sc.com/industrial-
service.php. [Accessed 22 February 2023].
[5] D. Lewis, "Puebla, Mexico - 19 June 1977," Loss Prevention Bulletin, No. 100, pp. 35-42, August 1991.
[6] R. E. Sanders, Chemical Process Safety - Learning from Case Histories (4th Edition), Elsevier, 2015.
[7] A. Sharp, "This Week in Delaware History: Amoco Plant Explosion Kills 6 Near New Castle," Delaware Online, 24 October 2018.
[Online]. Available: https://www.delawareonline.com/story/news/local/2018/10/24/delaware-history-amoco-plant-explosion-kills-
6-near-new-castle/1749241002/. [Accessed 24 February 2023].
[8] U.S. Chemical Safety and Hazard Investigation Board (CSB), "Key Lessons from the ExxonMobil Baton Rouge Refinery
Isobutane Release and Fire," 18 September 2017. [Online]. Available: https://www.csb.gov/exxonmobil-refinery-chemical-release-
and-fire/. [Accessed 18 March 2022].
[9] American Petroleum Institute, API Standard 599: Metal Plug Valves - Flanged, Threaded, and Welding Ends, 8th ed., 2020.
[10] T. Kletz, An Engineer's View of Human Error (Third edition), Rugby: Institution of Chemical Engineers (IChemE), 2001.
[11] C. Rosamond, "Locking wheel nuts explained: types, removal and lost keys," Auto Express, 19 May 2021. [Online]. Available:
https://www.autoexpress.co.uk/tips-advice/355041/locking-wheel-nuts-explained. [Accessed 24 February 2023].
[12] P. Jones, "Do All Cars Have Locking Wheel Nuts? (Checked)," Motor and Wheels, 15 August 2022. [Online]. Available:
https://motorandwheels.com/cars-with-locking-wheel-nuts/. [Accessed 24 February 2023].
[13] M. Fucich, "descote Valve IOM Training 2020 09," YouTube, [Online]. Available:
https://www.youtube.com/watch?v=rUkrPHPYxdI. [Accessed 24 February 2023].
[14] Steven Levy Enterprises, "Descote 4" 300# Bellows Seal Globe Valve," [Online]. Available:
https://www.slevysurplus.com/surplus-equipment/Valves/Valves/292148263740-DESCOTE-BELLOWS-SEAL-GLOBE-
VALVE-LCC-MATERIAL-FIG-B. [Accessed 24 February 2023].
[15] National Institute for Occupational Safety and Health (NIOSH), "DHHS (NIOSH) Publication No. 2015-198 - Workplace Design
Solutions: Supporting Prevention through Design (PtD) Using Business Value Concepts," August 2015. [Online]. Available:
https://www.cdc.gov/niosh/docs/wp-solutions/2015-198/pdfs/2015-198.pdf. [Accessed 16 May 2023].
[16] R. E. Sanders and W. L. Spier, "Monday Morning Quarterbacking: Applying PSM Methods to Case Histories of Yesteryear,"
Process Safety Progress, vol. 15, no. 4, Winter, 1996.
[17] LyondellBasell Industries Holdings, "Glacial Acetic Acid, 50%-80%," 2022. [Online]. Available:
https://www.lyondellbasell.com/en/chemicals/p/GLACIAL-ACETIC-ACID-50-80-/fda36b5b-9512-4c38-b0b5-7b30fd130bf6.
[Accessed 9 March 2022].
[18] Center for Chemical Process Safety (CCPS), Guidelines for Writing Effective Operating and Maintenance Procedures, Center for
Chemical Process Safety / AIChE, 1996.
[19] F. H. Hedlund, J. B. Pedersen, R. S. Selig, P.-U. Holmsen and E. K. Kragh, "Confusion due to Contractor Cascading Leads to
Major Release of Ammonia During Test of Safety Device," Chemical Engineering Transactions, vol. 74, pp. 1381-1386, 2019.
[20] Center for Chemical Process Safety, Guidelines for Risk Based Process Safety, Hoboken: American Institute of Chemical
Engineers and John Wiley & Sons, Inc., 2007.
[21] Census Reporter, "Census Reporter Profile - La Porte, TX," Census Reporter, 2023. [Online]. Available:
https://censusreporter.org/profiles/16000US4841440-la-porte-tx/. [Accessed 10 January 2023].
[22] U.S. Census Bureau, "Quick Facts - United States," U.S. Census Bureau, 2023. [Online]. Available:
https://www.census.gov/quickfacts/fact/table/US/SEX255221. [Accessed 10 January 2023].
[23] Occupational Safety and Health Administration, "OSHA Voluntary Protection Programs (VPP) / Current Federal and State-Plan
Sites," [Online]. Available: https://www.osha.gov/vpp/bylocation. [Accessed 9 March 2023].
[24] Occupational Safety and Health Administration, "Voluntary Protection Programs," [Online]. Available: https://www.osha.gov/vpp.
[Accessed 9 March 2023].

32
 Investigation Report

[25] R. Gulati, "4.2 Work Flow and Roles," in Maintenance and Reliability Best Practices, New York, Industrial Press, 2009, p. 76.
[26] U.S. Occupational Safety and Health Administration (OSHA), "1910.147 - The control of hazardous energy (lockout/tagout),"
OSHA, [Online]. Available: https://www.ecfr.gov/current/title-29/subtitle-B/chapter-XVII/part-1910/subpart-J/section-1910.147.
[Accessed 29 March 2022].
[27] U.S. Occupational Safety and Health Administration, "List of Highly Hazardous Chemicals, Toxics and Reactives (Mandatory),"
U.S. Department of Labor, 15 April 2019. [Online]. Available: https://www.osha.gov/laws-
regs/regulations/standardnumber/1910/1910.119AppA. [Accessed 23 March 2023].

33
 Investigation Report

APPENDIX A—CAUSAL ANALYSIS (ACCIMAP)

I

34
 Investigation Report

APPENDIX B—DESCRIPTION OF SURROUNDING AREA

The demographic information of the population residing within about one mile of the LyondellBasell La Porte
complex fence line is contained in Figure 12 and Table 2 below.

Figure 12. Census blocks within the

approximately one-mile distance from the
LyondellBasell La Porte complex fence line.
(Credit: Census Reporter, with annotations by
CSB)

Table 2. Demographic data for the approximately one-mile vicinity of the LyondellBasell La Porte complex.
(Credit: Census Reporter)
Number
Tract Median Per Capita of
Population Race and Ethnicity Types of Structures
Number Age Income Housing
Units

52.0% White 92% Single Unit

1.0% Black 0% Multi-Unit
0.0% Native 8% Mobile Home
2.0% Asian 0% Boat, RV, van, etc.
1 1,740 46.5 $45,721 689
0.0% Islander
0.0% Other
0.0% Two+
45.0% Hispanic

35
 Investigation Report

0.0% White 0% Single Unit

0.0% Black 0% Multi-Unit
2 0 N/A N/A N/A
0.0% Native 0% Mobile Home
0.0% Asian 0% Boat, RV, van, etc.
87% White 89% Single Unit
0% Black 0% Multi-Unit
0% Native 11% Mobile Home
0% Asian 0% Boat, RV, van, etc.
3 1,837 32.8 $35,167 610
0% Islander
0% Other
4% Two+
9% Hispanic
83% White 100% Single Unit
0% Black 0% Multi-Unit
0% Native 0% Mobile Home
0% Asian 0% Boat, RV, van, etc.
4 1,215 49.2 $57,752 410
0% Islander
0% Other
0% Two+
17% Hispanic
58% White 100% Single Unit
0% Black 0% Multi-Unit
0% Native 0% Mobile Home
0% Asian 0% Boat, RV, van, etc.
5 1,477 32.8 $38,156 459
0% Islander
0% Other
1% Two+
41% Hispanic

36
 Investigation Report

U.S. Chemical Safety and Hazard Investigation Board

Members of the U.S. Chemical Safety and Hazard Investigation Board:

Steve Owens
Chairperson

Sylvia E. Johnson, Ph.D.

Member

Catherine J. K. Sandoval
Member

37