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alkali industry and emergency responders. The CSB reviewed connection point nor the CTMV hose receptacle had a unique
pamphlets related to the equipment and processes at MGPI and size or shape to prevent incorrect connections. And, although
concluded that voluntary adherence to the information in these MGPI used padlocks and keys to open the caps on the fill lines
pamphlets could have prevented or mitigated the incident. in the unloading area, the sodium hypochlorite fill line was
unlocked at the time of the incident. Finally, neither MGPI nor
CI Pamphlet 96, “Sodium Hypochlorite Manual,” is a guidance Harcros verified that the connection was correct. Had MGPI
document intended to provide information about sodium voluntarily followed Pamphlet 96 before the incident, the
hypochlorite, its properties, manufacture, safe handling, incident might have been prevented or the likelihood reduced.

packaging, transportation and uses, and the regulations
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affecting these areas. A critical part of Pamphlet 96 is CI Pamphlet 64, “Emergency Response Plans for Chlor-Alkali,
Appendix D, “Guidance to Avoid Accidental Mixing,” a new Sodium Hypochlorite, and Hydrogen Chloride Facilities,” provides
addition to the prior edition. Recommended procedural the basics of an emergency response plan to be used, for example,
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steps for unloading in Appendix D include “verify[ing] that during an accidental release of chlor-alkali products. Among
the unloading connections/piping are correct (check labels, other things, the CI advises that employers provide escape
routing, etc.) [,] verify[ing] connections by a second person, respirators and consider steps to minimize the consequences of

[and] follow[ing] applicable regulations for monitoring/ a release on a building’s occupants in the design and operation
attendance.” Appendix D also recommends: of the building ventilation system. As described in Section
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5.4, ease of access to escape respirators became an issue for
• Locating sodium hypochlorite unloading connections operators during the incident, which meant that operators had
away from incompatible product loading/unloading to evacuate without respiratory protection. Furthermore, as
connections; described in Section 5.3, the Mod B control room ventilation
• Ensuring sodium hypochlorite piping is short, visible, system did not protect occupants from the plume. Had MGPI
and marked as best as possible so that the unloader voluntarily followed Pamphlet 64 before the incident, the
can trace the product piping from the connection severity of consequences that followed the inadvertent mixture

point to the receiving tank; might have been lessened. Because sodium hypochlorite is one
• Dedicating sodium hypochlorite unloading lines to of the chemicals handled by CI member companies, the CSB
avoid any compatibility issues; and intends to work with the CI to communicate the key lessons
• Considering the use of lockout systems to prevent from this Case Study at the completion of its investigation.
unloading into tanks prior to proper verification.
7.2 NATIONAL ASSOCIATION OF
CHEMICAL DISTRIBUTORS
As discussed, MGPI’s sodium hypochlorite fill line was located
only 18 inches from the sulfuric acid fill line, although the The National Association of Chemical Distributors (NACD) is
chemicals are incompatible. In addition, the closest sodium an international association of chemical distributors and their
hypochlorite pipe marker to the fill line connection point was supply-chain partners. Members consist of companies that
164
loosely attached to the line and appeared to be upside down. process, formulate, blend, re-package, store, transport, and market
It was not placed at the connection point or immediately
adjacent to the downstream elbow, which would have made
the line much easier to trace. Furthermore, while not identified 162 The Chlorine Institute. Emergency Response Plans for Chlor-Alkali, Sodium
Hypochlorite and Hydrogen Chlorite Facilities. Pamphlet 64; 7th ed.; The Chlorine
by Pamphlet 96, neither the sodium hypochlorite fill line Institute: Arlington, VA, November 2014.
163 The Chlorine Institute. Emergency Response Plans for Chlor-Alkali, Sodium
160 The Chlorine Institute. Pamphlet 96, Sodium Hypochlorite Manual, 4th ed.; The Hypochlorite and Hydrogen Chlorite Facilities. Pamphlet 64; 7th ed.; The Chlorine
Chlorine Institute: Arlington, VA, October 2011. Institute: Arlington, VA, November 2014.
161 The Chlorine Institute. Pamphlet 96, Sodium Hypochlorite Manual, 4th ed.; The 164 National Association of Chemical Distributors. https://www.nacd.com/about/about/
Chlorine Institute: Arlington, VA, October 2011. (accessed December 4, 2017).
CSB MGPI Processing Case Study 35