Formosa Plastics USA
April 23, 2004
TABLE OF CONTENTS
1.0 EXECUTIVE SUMMARY 2
2.0 DISCUSSION 2
3.0 RECOMMENDATIONS 4
4.0 CONCLUSIONS 5
5.0 REFERENCES 5
EXHIBIT A PSM Checklist 6
EXHIBIT B Photos – Illustrations 8
On April 23, 2004, the Formosa Plastics Corporation located in Illiopolis, Illinois, suffered a disastrous fire and explosion that resulted in 5 deaths and 3 seriously injured employees. The incident took place in the polyvinyl chloride (PVC) manufacturing facility which took out almost all of the reactor facility and warehouse storage of PVC resins. These resins were ignited after the initial explosion and began to produce large amounts of thick, dark smoke that began to disperse over an adjacent community. As a result, a mandatory evacuation of the community was ordered and lasted for 2 days.
It was determined that the explosion was the result of an operator draining a full, heated, pressurized PVC reactor. The operator had inadvertently opened the bottom valve on a reactor still in operation that caused a release of vinyl chloride monomer (VCM). VCM is a raw material used in the PVC manufacturing process and is considered extremely flammable. Reactor 306 was being cleaned for maintenance and required proper draining of the water and cleaning agent used for this process. Instead of draining reactor 306, the operator opened the bottom valve and drain valve of reactor 310 which was still in process. Extremely flammable vinyl chloride immediately began to pour out of the reactor and spread throughout the facility. An unknown ignition source was reached and caused a violent serious of explosions. 4 Operators were killed immediately and a fifth operator was seriously burned and died 2 weeks later. 2 other operators and the shift supervisory were severely injured.
It was concluded by CSB that procedures in place by both Borden Chemical, previous owners of the facility, and Formosa Plastics were insufficient to minimize the potential for human error. Formosa failed to properly train employees for proper procedure and evacuation upon release of these hazardous chemicals.
The Illiopolis, Illinois plant was originally constructed and operated by Borden, Inc. from 1965 to 1987. Ownership was then transferred to Borden Chemicals and Plastics. In 2001, Borden Chemical filed for bankruptcy and the facility was sold to Formosa Plastics Corporation USA in 2002. The EHS programs were reviewed by Formosa just prior to the sale. Good management practices were identified and none of these findings were directly related to the incident. The investigation by CSB, however, did find many root causes that both Borden Chemical and Formosa failed to identify.
2.1 Contributing Factors
A number of factors contributed to the severity of the incident: •Borden Chemical did not adequately address the potential for human error: Borden Chemical failed to implement 1992 process hazard analysis (PHA) recommendations to change the reactor bottom valve interlock bypass to reduce potential misuse. The bottom valve was equipped with a safety...