Safety Moment

Wrong material in the wrong tank:

A fatal reactive chemistry incident
02nd March 2011

 This safety moment describes a fatal incident

in which the incorrect material from a tank truck
was unloaded into a storage tank
This incident occurred on June 4, 1999 around 3.30 am
in Whitehall Leather Company, Michigan USA, and
was investigated by the United States National
Transportation Safety Board (NTSB)
The material from the truck reacted with the material in
the storage tank to produce highly toxic Hydrogen
Sulfide (H2S) gas
Two personnel were exposed to the toxic gas

Incident Background
The company operated a location that had several
chemicals stored in tanks at various locations in the plant
Water solutions of sodium hydrosulfide and ferrous sulfate
were among the chemicals received by truck and unloaded
into storage tanks
Plant procedure was to off load chemicals from the tanker
with the assistance of Shift Supervisor
Shift Supervisor was expecting a delivery of Ferrous
Sulfate

Incident Background
A tank truck containing Sodium Hydrosulfide arrived at the
plant
The Shift Supervisor escorted the driver to the Ferrous
Sulfate tank and authorized him to off load without
inspecting the truckers paperwork and left the unloading
area
The driver connected the piping to the tank and began
offloading Sodium Hydrosulfide through a connection
marked Ferrous Sulfate

Incident Scene
Unloading arrangement

Incident Scene
Unloading connection

Plant Layout
The truck of Sodium
Hydrosulfide was
supposed to be unloaded
to these tanks

It was actually hooked up

and unloaded to the
Ferrous Sulfate tanks at
this location

What happened ?
The unloading of Sodium Hydrosulfide in the Ferrous
Sulfate tank lead to a reaction which produced Hydrogen
Sulfide (H2S), a colorless gas which is highly toxic at
800ppm
An employee noticed an unusual odor and lost
consciousness
The operator regained consciousness after 10 minutes to
notify other employees to raise an emergency
The truck driver was found unconscious and later
pronounced dead at the scene due to exposure to H2S gas

Plant Layout
The truck driver
was found
unconscious at
this location and
died from
Hydrogen Sulfide
exposure
An operator
passed out at this
location, but
fortunately
recovered in time
to get help

Why did this happen ?

The Shift Supervisor assumed the contents of the
delivery based on experience and what he was
expecting to receive
The Standard Operating Procedure for unloading of
chemicals was not followed
No plant employee observed the off-loading and there
was no method of communication at the unloading area
Sampling procedure of the chemicals was also not
adopted in the unloading area

Lessons Learnt
A Standard Operating Procedure for unloading chemicals
in storage tanks was developed and a unloading check
sheet was also maintained in every shift
Company designated two authorized personnel to assist
the driver in unloading of bulk shipments
Company also placed barrier gates at the entrances to
the bulk chemical unloading areas
An emergency remote alarm button was installed at each
material transfer location

Best Practice
Surprise inspection to be conducted by Safety and Environment
officers during unloading of chemicals from tankers in all shifts
Reaction Chemistry needs to be known to the Shift Supervisor
responsible for unloading the chemicals

Tank vents need to be directed to a safe location so people will not

be exposed to toxic vapors vented from the tank
Unloading connections and piping clearly need to be labeled with
paddle lock to avoid unauthorized unloading of chemicals in the
tanks
Company to conduct program to train its employees for unloading
bulk cargo

THANK YOU