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January 1, 2014, eight incidents similar to the MGPI
incident have occurred involving incompatible materials and
Holly Hill Incident
resulting in a chemical reaction. These incidents resulted in
44 injuries and the evacuation of 846 individuals (Table 3).
The Pipeline and Hazardous Materials Safety Administration
Table 3. Incidents involving inadvertent mixing from PHMSA Database
(Source: CSB). (PHMSA) investigated a similar incident to the MGPI
incident in 2015 that occurred in Holly Hill, Florida. PHMSA
PHMSA Totals: (January 1, 2014 found that the driver of the tank truck connected a delivery
through June 9, 2017) hose from a truck filled with sodium hypochlorite to a
Incidents: 8 fill line to two storage tanks containing sulfuric acid. The

Injuries: 44 mixture of the two materials caused a release of gas that
Hospitalizations: 2 overcame the operator and several local residents.

Individuals Evacuated: 846
The DOT investigative team found that the “company’s
SOP and related training for unloading of cargo tanks
Analysis of the data reveals that these incidents occur periodically
violated the attendance requirement during unloading as
and are not tied to specific industries; for instance, incidents
stipulated by 49 C.F.R. § 177.834(i), in that the process is
have occurred at water treatment plants, generation plants,
to open valves on the cargo tank and fixed storage tanks to
public and private swimming pools, as well as at other industrial
begin flow of liquid then leave the rear of the cargo tank
facilities. These incidents can lead to injuries and evacuations
to climb into the cab of the tractor to start the engine and
due to potentially violent chemical reactions and harmful gases
build up air pressure.” The DOT investigative team found
entering the air. Inadvertent mixing during unloading can occur
that sitting in the cab of the tractor put the operator some
at any facility that receives more than one type of chemical. The
40 feet away from the rear of the cargo tank and delivery
CSB concludes that adopting key lessons and recommendations
hose and would not have provided an unobstructed
resulting from this Case Study, in addition to recognized industry
view of the hose and activities during the unloading
and regulatory guidance, can prevent similar incidents.
operation. As a result, the operator would be unaware of
7.0 INDUSTRY ASSOCIATIONS AND GUIDANCE any abnormalities occurring at the connection until he

7.1 CHLORINE INSTITUTE returned. In the Holly Hill incident, the driver apparently
The Chlorine Institute (CI) is a technical trade association that walked into the chemical gas cloud when returning to the
focuses on the production, distribution, and use of chlor- rear of the vehicle after the situation was out of control.
alkali chemicals. CI members include chlorine producers,
157
158
packagers, distributors, users, and suppliers, and its North
American producer members account for a majority of the total a Member Safety and Security Commitment and Pamphlet
chlorine production capacity of the United States and Canada. Certification annually, certifying that they will promote and
demonstrate safety and security and that they have implemented
As part of its chlorine stewardship program, the CI requires and comply with stewardship policies, which include safety
its members that produce, distribute, or use chlorine to sign and security audits and hazard evaluations of chlor-alkali
159
operations. Additionally, the CI has developed many safety
156 Up to and including June 9, 2017. resources and technical pamphlets that provide guidelines,
157 Chlor-alkali products refer to chlorine, sodium hydroxide, potassium hydroxide, recommended practices, and other information for the chlor-
sodium hypochlorite, anhydrous hydrogen chloride, and hydrochloric acid
collectively.
158 The Chlorine Institute. https://www.chlorineinstitute.org/about-us/ (accessed 159 The Chlorine Institute. https://www.chlorineinstitute.org/hess/hess-overview/
September 12, 2017). (accessed November 15, 2017).
34 CSB MGPI Processing Case Study