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Final report and incident animation released into 2018 chemical plant explosion that injured 23

03 January 2023

The US Chemical Safety and Hazard Investigation Board (CSB) has released its final investigation report and incident animation for the 2018 fire that injured 23 workers at the Kuraray America, Inc. EVAL plant in Pasadena, Texas.

The CSB’s report explains the events leading up to the incident, including how the incident occurred during the start-up of a chemical reactor system following a scheduled maintenance shutdown – also referred to as a turnaround. High pressure conditions developed inside the reactor and activated the reactor’s emergency pressure relief system, discharging flammable ethylene vapour through piping into an area where a number of contractors were working. Over one tonne of ethylene was released in approximately three minutes. The work being done by the nearby contractors included welding, which most likely ignited the flammable vapour.


Among the 23 workers injured during the incident, two were life-flighted from the facility, one of whom remained in critical condition for several days because of burn injuries. As many as 19 others were transported to the hospital by emergency responders for various injuries.


The CSB’s animation depicts the incident and the events leading up to it.


The CSB determined that the cause of the incident was Kuraray’s emergency pressure relief system design that discharged flammable ethylene vapour from the reactor through horizontally aimed piping into the air in an area near workers. If Kuraray’s emergency pressure relief system had been designed to discharge the vapour to a safe location, the flammable ethylene gas should not have harmed any workers.


CSB Chairperson Steve Owens said: “Kuraray could have prevented the injuries to these workers by ensuring that the flammable ethylene gas discharged from its system was directed to a safe location. Kuraray also should have evacuated these workers from the area when the reactor’s high-pressure alarm sounded, since it was signalling a serious problem with the reactor.”


The CSB’s investigation report details a chain of process safety management failures that led to the build-up of excessive pressure inside the reactor. The emergency pressure relief system discharge design is just one of the 17 safety issues identified by the CSB in the report. The additional 16 safety issues are:


- Presence of nonessential workers during start-up and upset conditions
- Hazardous Location
- Recognised and generally accepted good engineering practices
- Process hazards analysis safeguards
- Process hazard analysis recommendations
- Warning signs
- Equipment design
- Operating procedures
- Operator training
- Abnormal operating conditions
- Safety interlock disabling
- Alarm management
- Process alarm response
- Safe operating limits
- Environmental permit limits
- Safety management system self-assessment audits


The CSB is making several safety recommendations to the company, including a call for Kuraray America to develop and implement a standard to ensure that these safety systems discharge to a safe location.


CSB Board Member Sylvia Johnson said: “The CSB’s final report and safety recommendations aim to take the valuable lessons learned from our investigations and implement necessary changes to improve workplace safety throughout this facility and across the industry.”


Read the CSB's final investigation report by clicking here.


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