Federal investigators say mistakes by a delivery driver and an employee of a northeast Kansas distilling plant led to the mixing of incompatible chemicals, causing a noxious cloud to spread over Atchison last year.
The U.S. Chemical Safety Board said in a preliminary report issued Wednesday that design and labeling deficiencies at the loading station at MGP Ingredients also contributed to the toxic chemical release of a huge cloud of chlorine gas in October 2016.
The release sent about 140 people to hospitals and caused residents in the area to stay indoors or evacuate for several hours.
The full press conference can be watched in the video above.
The CSB investigation found around 7:35 a.m. on that day, a Harcros Chemicals truck came to MGPI to deliver sulfuric acid. That driver should've unloaded sulfuric acid into the sulfuric acid tank, but instead put it into the unlocked sodium hypochlorite fill line. This should've never been unlocked. The chemicals reacted, releasing thousands of gallons of the gas across the region.
6 key findings from the CSB
1. Facility should ensure labeling of transfer equipment is clear and accurate. It should represent the material contained in the equipment. Label should be close to the fill line points.
2. Neither MGPI nor Harcros followed chemical and loading procedures at the time of the incident. Following these procedures may have prevented the incorrect connection and allowed for an earlier mitigation of the release once the chemical reaction began.
3. MGPI had no way to stop the truck from continuing to empty its contents into the incorrect tank because the facility did not have an emergency shutdown in place that could be accessed remotely.
4. Facilities that receive bulk chemicals should consider the use of automated valves at control stations that can be closed remotely from control rooms. On the day of the incident, chlorine gas quickly filled the control room and operators were unable to safely mitigate the release by manually closing the sodium hypochlorite valve located outside the fill line.
5. Emergency shutoff valves and trucks should be activated when necessary. Driver should be fully trained on the appropriate use of such emergency equipment.
6. Mitigation of any incident is integral introducing the severity of impact, while improving the design and operation of transfer equipment can ensure chemicals are unloaded safely and without incident.
MGP Ingredients, Inc. released the following statement after the news conference:
The CSB is a governing body that overlooks the process and is presenting key findings so that MGPI may reduce its risk of such an incident happening again. It does not give fines or sanctions.
It did say that MGPI has made changes in its delivery and labeling process.
The CSB will present recommendations in the fall.
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