Page 39 - MGPI_Case_Study

In 2014, with input from OSHA and EPA, PHMSA issued roles and responsibilities for valve operation might not have
the “Cargo Tank Motor Vehicle (CTMV) Loading/Unloading been switched between facility personnel and CTMV drivers,
Operations: Recommended Best Practices Guide” (PHMSA and critical steps missing from the procedures could have
194
199
Guide). PHMSA, at the same time, published a two- been identified and corrected. In addition, MGPI might
page companion pocket guide (PHMSA Companion Guide) have identified the incorrect pipe marking at Mod B and lack
200
to serve as a reference for chemical delivery drivers. of signs or pipe markers at the connection points. PHMSA
states that employers should use these risk assessments to
201
The PHMSA Guide provides various best practices for training, implement new, or enhance existing, operating procedures.
conducting risk assessments and audits, and implementing
clear operating procedures based on those assessments and Prior to the incident, both Harcros’ and MGPI’s procedures
195
audits. PHMSA recommends that all hazmat employees, required verification that material is being transferred into
whether employed by a carrier or facility, be evaluated annually the appropriate tank and that the tank has sufficient room
to gauge their understanding of safe loading/unloading to receive the chemical; however, both procedures relied on
procedures. Employees should also be observed and oral communication between the driver and operator. Certain
196
evaluated and feedback provided on the performance of their design issues, such as adding distance between incompatible

duties. The CSB found that neither MGPI nor Harcros had connections, selecting unique fittings, and applying clearer
197
a program or process for evaluating and providing feedback pipe markings, could greatly reduce the likelihood of incorrect
to Mod B employees performing unloading operations or connections. The PHMSA Guide also suggests implementing
Harcros drivers. Had MGPI and Harcros actively monitored engineering controls to avoid the mixture of incompatible
operators while unloading, the companies may have become materials (Figure 17). Had these suggested engineering controls
202
aware that operators and drivers were not adhering to been implemented, the incident may have been avoided. The
unloading procedures as written and could have provided PHMSA Guide also recommends that facility operators provide
198
appropriate feedback and training to correct deficiencies. oversight of carrier personnel during unloading operations,
including supervision during unloading, and providing carriers

PHMSA also recommends that parties who load or unload with written instructions, or at least sufficient information,
CTMVs perform a risk assessment of the operation, including to allow carriers to comply with unloading procedures.
clearly identifying whether facility personnel or the CTMV
operator is responsible for each loading/unloading activity.
Procedures used to ensure safe loading/unloading should
also be assessed to identify areas for improvement. Had MGPI
management completed a risk assessment prior to the incident,

194 Cargo Tank Motor Vehicle (CTMV) Loading/Unloading Operations: Recommended
Best Practices Guide, https://hazmatonline.phmsa.dot.gov/services/publication_
documents/CTMV%20Guidelines.pdf (accessed December 7, 2017).
195 Cargo Tank Motor Vehicle (CTMV) Loading/Unloading Operations: Recommended
Best Practices Guide, https://hazmatonline.phmsa.dot.gov/services/publication_
documents/CTMV%20Guidelines.pdf (accessed December 7, 2017). Figure 17. Excerpt from “CTMV Loading/Unloading Operations:
196 Cargo Tank Motor Vehicle (CTMV) Loading/Unloading Operations: Recommended Recommended Best Practices Guide” (Source: PHMSA).
Best Practices Guide, pp 5. https://hazmatonline.phmsa.dot.gov/services/
publication_documents/CTMV%20Guidelines.pdf (accessed December 7, 2017).
197 Cargo Tank Motor Vehicle (CTMV) Loading/Unloading Operations: Recommended 199 See Section 5.1.3 for a discussion of Operating Procedures.
Best Practices Guide, pp 5 https://hazmatonline.phmsa.dot.gov/services/publication_
documents/CTMV%20Guidelines.pdf (accessed December 7, 2017). 200 See Section 5.1.2 for an analysis of MGPI’s labelling deficiencies.
201 Cargo Tank Motor Vehicle (CTMV) Loading/Unloading Operations: Recommended
198 Post-incident, MGPI changed its unloading procedure and, among other changes,
now requires a salaried employee to observe operators during unloading. See Best Practices Guide, https://hazmatonline.phmsa.dot.gov/services/publication_
Section 5.1.3 for a discussion of procedural deficiencies and Section 9.0 for an documents/CTMV%20Guidelines.pdf (accessed December 7, 2017).
analysis of MGPI’s updated procedures. 202 See Section 5.1.1 for an analysis of MGPI’s design of chemical transfer equipment.
CSB MGPI Processing Case Study 39