Investigation Report
Organic Peroxide Decomposition, Release, and Fire at
Arkema Crosby Following Hurricane Harvey Flooding
Crosby, Texas

Incident Date: August 31, 2017
Exposures to Emergency Responders, Community Evacuation, and Property Damage

KEY ISSUES:••••

Understand Site Flood Vulnerability
Conduct a Flood Risk Assessment
Strengthen Flood Resiliency
Improve Emergency Response

Report Number: 2017-08-I-TX
May 2018

The U.S. Chemical Safety and Hazard Investigation Board (CSB) is an independent Federal
agency whose mission is to drive chemical safety change through independent investigations
to protect people and the environment.

The CSB is a scientific investigative organization, not an enforcement or regulatory body.
Established by the Clean Air Act Amendments of 1990, the CSB is responsible for determining
accident causes, issuing safety recommendations, studying chemical safety issues, andevaluating the effectiveness of other government agencies involved in chemical safety. Moreinformation about the CSB is available at www.csb.gov.

The CSB makes public its actions and decisions through investigative publications, all ofwhich may include safety recommendations when appropriate. Types of publications include:
Investigation Reports: formal, detailed reports on significant chemical incidents that
include key findings, root causes, and safety recommendations.
Investigation Digests: plain-language summaries of Investigation Reports.
Case Studies: reports that examine fewer issues than Investigation Reports.
Safety Bulletins: short publications typically focused on a single safety topic.
Hazard Investigations: broader studies of significant chemical hazards.
Safety Videos: videos that animate aspects of an incident or amplify CSB safety
messages.

CSB products can be freely accessed at www.csb.gov or obtained by contacting:
U.S. Chemical Safety and Hazard Investigation Board
Office of Congressional, Public, and Board Affairs
1750 Pennsylvania Ave NW, Suite 910
Washington, DC 20006(202) 261-7600
No part of the conclusions, findings, or recommendations of the Board relating to any
accidental release or the investigation thereof shall be admitted as evidence or used in any
action or suit for damages arising out of any matter mentioned in such report. See 42 U.S.C.
§ 7412(r)(6)(G).

2

CSB · Investigation ReportTable of Contents
ABBREVIATIONS, ACRONYMS, AND INITIALISMS ................................................................................................... 6
1.

SUMMARY ..................................................................................................................................................... 8
1.1.
OVERVIEW OF INCIDENT EVENTS AND ACTIVITIES.....................................................................................................8
1.1.1.
Preparing for Hurricane Harvey ...........................................................................................................9
1.1.2.
Relocation of Organic Peroxides ........................................................................................................10
1.1.3.
Emergency Response Activities..........................................................................................................121.2.
KEY FINDINGS AND LESSONS..............................................................................................................................13
1.3.
GUIDANCE TO INDUSTRY...................................................................................................................................16
1.4.
SUMMARY OF RECOMMENDATIONS ....................................................................................................................162.

BACKGROUND INFORMATION ON ARKEMA CROSBY OPERATIONS ............................................................. 18
2.1.
2.2.
2.3.
2.4.
2.5.
2.6.
2.7.

3.

INCIDENT DESCRIPTION ............................................................................................................................... 27
3.1.
3.2.
3.3.
3.4.
3.5.
3.6.
3.7.
3.8.
3.9.
3.10.
3.11.
3.12.

4.

THURSDAY, AUGUST 24, 2017 .........................................................................................................................30
FRIDAY, AUGUST 25, 2017 ..............................................................................................................................32
SATURDAY, AUGUST 26, 2017..........................................................................................................................33
SUNDAY, AUGUST 27, 2017 .............................................................................................................................36
MONDAY, AUGUST 28, 2017 ...........................................................................................................................43
TUESDAY, AUGUST 29, 2017............................................................................................................................50
WEDNESDAY, AUGUST 30, 2017 ......................................................................................................................55
THURSDAY, AUGUST 31, 2017 .........................................................................................................................58
FRIDAY, SEPTEMBER 1, 2017 ............................................................................................................................61
SATURDAY, SEPTEMBER 2, 2017 .......................................................................................................................63
SUNDAY, SEPTEMBER 3, 2017 ..........................................................................................................................65
MONDAY, SEPTEMBER 4, 2017.........................................................................................................................66

FLOOD INFORMATION ................................................................................................................................. 67
4.1.
4.2.
4.3.
4.4.

5.

ORGANIC PEROXIDES .......................................................................................................................................18
ORGANIC PEROXIDE STORAGE BUILDINGS ............................................................................................................20
REFRIGERATION ..............................................................................................................................................21
EMERGENCY GENERATORS ................................................................................................................................22
LIQUID NITROGEN SYSTEM................................................................................................................................23
REFRIGERATED TRAILERS...................................................................................................................................24
PRODUCT TOTES .............................................................................................................................................25

HISTORY OF FLOOD INSURANCE RATE MAP FOR THE ARKEMA CROSBY FACILITY...........................................................75
FLOOD INSURANCE STUDY ................................................................................................................................78
BASE FLOOD ELEVATION ...................................................................................................................................79
2016 INSURANCE REPORT IDENTIFIED AND EVALUATED FLOOD RISK.........................................................................81

FLOOD DESIGN AT THE ARKEMA CROSBY FACILITY ...................................................................................... 83
5.1.
5.2.
5.3.

HURRICANE PREPAREDNESS PLAN ......................................................................................................................83
EMERGENCY RESPONSE PLAN ............................................................................................................................83
STORAGE BUILDING SAFETY GUIDELINES ..............................................................................................................84

CSB · Investigation Report

3

5.4.
5.5.
5.6.
6.

PROCESS HAZARD ANALYSIS ..............................................................................................................................84
PROCESS SAFETY WORST-CASE SCENARIOS ..........................................................................................................86
ARKEMA STATEMENTS .....................................................................................................................................86

FLOOD PLANNING GUIDANCE...................................................................................................................... 88
6.1.
AMERICAN SOCIETY OF CIVIL ENGINEERS .............................................................................................................88
6.2.
CENTER FOR CHEMICAL PROCESS SAFETY .............................................................................................................89
6.2.1.
Guidelines for Safe Warehousing of Chemicals .................................................................................89
6.2.2.
Guidelines for Safe Storage and Handling of Reactive Materials ......................................................90
6.2.3.
Guidelines for Technical Planning for On-Site Emergencies ..............................................................91
6.3.
FEDERAL EMERGENCY MANAGEMENT AGENCY .....................................................................................................91
6.4.
EPA FACILITY DESIGN PRACTICE ........................................................................................................................91
6.5.
FM GLOBAL ...................................................................................................................................................92
6.6.
UNITED KINGDOM ENVIRONMENT AGENCY ..........................................................................................................93
6.7.
CHEMICAL INDUSTRIES ASSOCIATION ..................................................................................................................95
6.8.
UNITED NATIONS DISASTER RISK REDUCTION .......................................................................................................96

7.

REGULATORY ANALYSIS............................................................................................................................... 98
7.1.
FLOOD HAZARDS .............................................................................................................................................98
7.1.1.
United States Approach .....................................................................................................................98
7.1.1.1.
7.1.1.2.

OSHA Process Safety Management Standard ............................................................................................... 98
EPA Risk Management Program ................................................................................................................... 99

7.1.2.
European Union Approach ..............................................................................................................101
7.2.
REACTIVE HAZARDS .......................................................................................................................................101
8.

HOW COMPANIES CAN EVALUATE FLOOD RISK AT THEIR FACILITIES ......................................................... 103

9.

OTHER FLOODING INCIDENTS .................................................................................................................... 107
9.1.
9.2.

FUKUSHIMA DAIICHI ACCIDENT REPORT ............................................................................................................107
SAN JACINTO PIPELINE FLOODING INCIDENT .......................................................................................................10910.

EMERGENCY RESPONSE ACTIVITIES ....................................................................................................... 112

11.

EVACUATION ZONE ............................................................................................................................... 113

11.1. SULFUR DIOXIDE ...........................................................................................................................................113
11.2. ISOBUTYLENE................................................................................................................................................114
11.3. STILL-UNKNOWN POTENTIAL HEALTH EFFECTS FROM THE RELEASE AND BURNING OF ORGANIC PEROXIDES AT THE ARKEMAFACILITY .................................................................................................................................................................115
11.4. STAFFING RESOURCES ....................................................................................................................................116
11.5. KEEPING HIGHWAY 90 OPEN ..........................................................................................................................117
12.

FREQUENCY AND COST OF FLOODING NATURAL DISASTERS ................................................................. 119

13.

NATECH RISK ASSESSMENT AND MANAGEMENT .................................................................................. 122

14.

HURRICANE HARVEY OTHER INDUSTRIAL RELEASES .............................................................................. 124

15.

RECOMMENDATIONS ............................................................................................................................ 126

15.1.
15.2.

4

REITERATED RECOMMENDATIONS FROM REACTIVES STUDY TO THE ENVIRONMENTAL PROTECTION AGENCY ...................126
ARKEMA CROSBY FACILITY ..............................................................................................................................126

CSB · Investigation Report15.3.
15.4.
15.5.
16.

ARKEMA INC. ...............................................................................................................................................126
CCPS .........................................................................................................................................................127
HARRIS COUNTY ...........................................................................................................................................127
REFERENCES .......................................................................................................................................... 128

APPENDIX A: CAUSAL ANALYSIS ........................................................................................................................ 143
APPENDIX B: ADDITIONAL ORGANIC PEROXIDE INFORMATION........................................................................ 144
APPENDIX C: LOSS OF REFRIGERATION RISK ASSESSMENT ................................................................................ 146
Harvey Flooding – Simulated Risk Assessment .................................................................................................149
Resilience from Extreme Weather Events .........................................................................................................152

CSB · Investigation Report

5

ABBREVIATIONS, ACRONYMS, AND INITIALISMS
ACC
AEGL
AEP
ALARA
ALARP
API
AQI
ASCE
ASPECT
BFE
BOC
CCPS
CDL
CFR
COMAH
CSB
CVFD
DOT
EPA
EPR
EU-JRC
FEMA
FIA
FIRM
FIS
HCFCD
HSE
IAEA
KOP
LOPA
NFPA
NIMS
NOAA
NTSB
OSHA
PHA
PSM
PVC
RAGAGEP
RMP
RP
SDS
6

CSB · Investigation Report

American Chemistry Council
Acute Exposure Guideline Level
Annual Exceedance Probability
As Low As Reasonably Achievable
As Low As Reasonably Practicable
American Petroleum Institute
Air Quality Index
American Society of Civil Engineers
Airborne Spectral Photometric Environment Collection Technology
Base Flood Elevation
Bottom of Channel
Center for Chemical Process Safety
Commercial Driver License
Code of Federal Regulations
Control of Major Accident Hazards
U.S. Chemical Safety and Hazard Investigation Board
Crosby Volunteer Fire Department
U.S. Department of Transportation
U.S. Environmental Protection Agency
Environmental Permitting Regulations
European Commission’s Joint Research Centre
Federal Emergency Management Agency
Federal Insurance Administration
Flood Insurance Rate Map
Flood Insurance Study
Harris County Flood Control District
Health and Safety Executive
International Atomic Energy Agency
King of Prussia
Layer of Protection Analysis
National Fire Protection Association
National Incident Management System
National Oceanic and Atmospheric Administration
National Transportation Safety Board
Occupational Safety and Health Administration
Process Hazard Analysis
Process Safety Management
Polyvinyl Chloride
Recognized and Generally Accepted Good Engineering Practice
Risk Management Plan
Recommended Practice
Safety Data Sheet

SADT
SCBA
SDS
TCEQ
TEPCO
TOB
TVA
U.K.
UN
U.S.
USACE
USCG
USGS

Self-Accelerating Decomposition TemperatureSelf-Contained Breathing Apparatus
Safety Data Sheet
Texas Commission on Environmental Quality
Tokyo Electric Power Company
Top of Bank
Tennessee Valley Authority
United Kingdom
United Nations
United States of America
U.S. Army Corps of Engineers
U.S. Coast Guard
U.S. Geological Survey

CSB · Investigation Report71. SUMMARY
1.1.

OVERVIEW OF INCIDENT EVENTS AND ACTIVITIES1.

On August 24, 2017, Hurricane Harvey, a Category 4 hurricane, made landfall in southeast Texas.
Over the next several days, the storm produced unprecedented amounts of rainfall over southeast
Texas and southwest Louisiana, causing significant flooding. Hurricane Harvey turned out to be
the most significant tropical cyclone rainfall event and the second most costly hurricane in U.S.
history, after Hurricane Katrina. Over the course of the storm, Hurricane Harvey killed 68 people
and flooded over 300,000 structures, forcing roughly 40,000 people to evacuate their homes.
Hurricane Harvey required a large emergency response effort supported by local, state, and Federal
officials.

2.

The Arkema Crosby facility is located within the 100-year and 500-year flood plain.a Extensive
flooding caused by heavy rainfall from Hurricane Harvey exceeded the equipment design
elevations and caused the plant to lose power, backup power, and critical organic peroxide
refrigeration systems. Consequently, Arkema used its standby refrigerated trailers to keep theorganic peroxide products cool. This flooding also eventually forced all Arkema’s employees toevacuate from the facility. A Unified Command established a 1.5-mile evacuation zone around theArkema facility and helped transport residents out of this zone for their safety.

3.

On August 31, 2017, organic peroxide products stored inside a refrigerated trailer decomposed,
causing the peroxides and the trailer to burn. Twenty-one people sought medical attention fromexposure to fumes generated by the decomposing products when the vapor travelled across a public
highway adjacent to the plant. Emergency response officials initially decided to keep this highway
open, despite the fact that it ran through the established evacuation zone around the Arkema
facility, because this road served as an important route for hurricane recovery efforts. Over the next
several days, a second fire and a controlled burn conducted by the Unified Command consumed
eight more trailers holding Arkema’s remaining organic peroxide products that required lowtemperature storage. Over the course of the three fires, in excess of 350,000 pounds of organic
peroxide combusted. As a result, more than 200 residents living within 1.5 miles of the facility
who had evacuated the area could not return home for a week. Figure 1 provides a timeline for theincident events and activities that unfolded at the Arkema Crosby facility as Hurricane Harvey
moved through southeast Texas and flooded the site.

a

A 100-year flood plain, also called the base flood elevation, is an area that has a one percent risk for flooding in any given year.
A 500-year flood plain is an area with a 0.2 percent risk for flooding in any given year.

8

CSB · Investigation ReportFigure 1. Overview Timeline for the Incident Events and Activities at the Arkema Crosby Facility.

1.1.1. PREPARING FOR HURRICANE HARVEY
4.

After Hurricane Harvey had traveled through the Gulf of Mexico for over 10 days, on Wednesday,
August 24, 2017, it became clear that the storm would impact the middle and upper Texas coast andlikely stall over Texas [1]. Meteorologists projected that the storm would make landfall on Friday,
August 25, 2017, bringing heavy rainfall of 12 to 20 inches across much of Texas, with some areas
predicted to receive as much as 30 inches over the duration of the storm [2]. In anticipation of
Hurricane Harvey, personnel at the Arkema Crosby facility began to prepare even though they were
not projected to be in the direct path of the storm.

5.

The Arkema Crosby facility had a written hurricane preparedness plan that detailed how the siteplanned to protect workers and property before, during, and after a hurricane. On Thursday, August24, 2017, Arkema personnel decided that the plant needed to be readied in the event the hurricane
affected the Crosby facility. Based on the collective experience of Arkema Crosby facility
employees, the predicted amount of rain would likely flood surrounding roads and necessitate
activating a “ride-out crew.” The ride-out crew would remain onsite because other workers would
have difficulty getting to or leaving the facility. None of the Crosby employees, however,anticipated the amount of rain or level of flooding, or the potential for catastrophic damage that
could result. Employees with decades of plant experience expected light flooding at the facility, but
not enough to impair any safety systems.

CSB · Investigation Report96.

Following its hurricane preparedness plan, on Friday, August 25, 2017, Arkema halted production
and took many precautions to prepare for the storm. These precautions included securing loosematerials that could blow away or cause damage in the expected winds; elevating portableequipment to keep it out of floodwater; acquiring a boat and a forklift that could operate infloodwater; staging sandbags and other equipment; and ensuring adequate reserve fuel levels. In
addition, the Arkema Crosby facility activated its ride-out crew and Arkema later initiated its
corporate “crisis team” to help manage the potential effects of the hurricane on all of the Arkema
facilities in the Gulf area.

1.1.2. RELOCATION OF ORGANIC PEROXIDES
7.

All of the organic peroxides manufactured and stored at the Arkema Crosby facility can decompose
and combust if they are not kept below critical temperatures, referred to as Self-Accelerating
Decomposition Temperatures (SADTs). Some of the organic peroxide products at the Crosby
facility had SADTs low enough that they required continuous refrigeration to prevent
decomposition. This meant that organic peroxide products located in the refrigerated organic
peroxide cold storage buildings (“Low Temperature Warehouses”), which were maintained attemperatures as low as -20 °F (degrees Fahrenheit), would need to be moved to other refrigerated
areas to be kept cold if the warehouses lost electrical power and could not provide the required
refrigeration.

8.

As Hurricane Harvey stalled over Houston and began to pour unprecedented amounts of rain in thearea, the ride-out crew monitored the conditions of the plant as floodwater rose at the Arkema
Crosby facility. As the storm progressed, it became apparent that if the water level continued torise, the ride-out crew would need to de-energize electrical equipment proactively to prevent shortcircuiting. Based on their experience, however, the ride-out crew members still believed that theevent would be manageable and that the hurricane would only minimally affect safety at thefacility. Throughout the storm, the ride-out crew thought the water levels would stop rising, and ifthey could just manage the next few hours, the water would begin to drop.

9.

On Sunday, August 27, 2017, the National Hurricane Center stated, “Harvey continues to meander
over southeastern Texas, where it is producing catastrophic and life-threatening flooding rainfall[3].” Significant flooding occurred at the facility early on Sunday and the ride-out crew
preemptively shut down power to several of the Low Temperature Warehouses before the risingwater reached any of the electrical equipment.

10.

By Sunday afternoon, parts of the Crosby facility had approximately four feet of standing water.
As the water level rose, it threatened the continued operation of the Low Temperature Warehouse’s
refrigeration systems, so workers began moving the organic peroxide products into refrigerated
truck trailers which were located onsite. Even when half of the Low Temperature Warehouses
were manually powered off due to the rising floodwater level, the ride-out crew still believed
sufficient storage space remained because the crew members did not believe that they would lose
another warehouse. When the trailers were filled with product from Low Temperature Warehouses,
they were then moved to a high location on the facility’s grounds, referred to as the laydown area,
where these refrigerated trailers could operate and continue to cool the organic peroxide products.

10

CSB · Investigation Report

11.

Heavy rainfall continued in the area, and the water level at the Arkema Crosby site kept rising.
Workers continued to turn off power to additional Low Temperature Warehouses, which required
them to move the organic peroxide products to other locations. By Sunday night, confronted by therising floodwater, workers shut off power to all but one of the seven Low Temperature Warehouses
and moved the organic peroxide products to refrigerated trailers. By the end of the day on Monday,
there were six refrigerated trailers sitting on the high ground at the facility.

12.

Around 2:00 am on Monday morning, August 28, 2017, the floodwater reached the site’s main
power transformers and every building onsite lost power. Backup generators turned on
automatically, but the rising floodwater forced workers to turn them off for their safety. As a result,the last remaining Low Temperature Warehouse lost power.

13.

Throughout the day on Monday, the equipment that workers used to move the refrigerated trailers
and pallets of organic peroxide began to fail as the high level of floodwater affected electricalcomponents in the forklifts and the semi-tractor trucks used at the facility. At this point, the rideout crew found itself unable to move the refrigerated trailers to higher elevation in the facility, andwas no longer able to lift the pallets of organic peroxide product. Moreover, the water level in theplant around the Low Temperature Warehouses was now about chest-high, making it difficult for
the ride-out crew members to move about the site.

14.

By the end of the day on Monday, the workers were manually transferring the remaining smallorganic peroxide containers, about 2,160 in all, into the final remaining refrigerated trailer from thelast Low Temperature Warehouse, which had lost power. By this time, the workers had moved
nearly 10,500 containers (over 350,000 pounds) of products into nine refrigerated trailers. Three of
those trailers, containing more than 4,000 containers, however, could not be taken to the higher
elevation area due to the floodwater and were now in danger of losing refrigeration as thefloodwater began to overflow into their fuel tanks.

15.

Arkema corporate personnel determined that if the refrigerated trailers lost power, the organic
peroxide products inside would reach their SADT within a few days and combust. Arkema
personnel then alerted local emergency responders about this evolving situation. Arkema also
provided the Unified Command with refrigerated trailer telemetry data and estimated SADTs of theorganic peroxides for six of the refrigerated trailers beginning midday on Wednesday August 30,
2017.

16.

On the morning of Tuesday, August 29, 2017, Arkema requested that emergency responders
evacuate the ride-out crew. After the evacuation, emergency responders implemented a 1.5-mileevacuation zone around the facility based on modeling performed that assumed the refrigerated
trailers would combust. Arkema warned the Unified Command about the hazards of organic
peroxide decomposition and alerted them that emergency responders who may be exposed to thismaterial should wear personal protective equipment and self-contained breathing apparatus.

CSB · Investigation Report111.1.3. EMERGENCY RESPONSE ACTIVITIES
17.

While it was becoming apparent that a reactive chemical incident would occur at the Arkema
Crosby facility―and while emergency responders were dealing with that eventuality―the massive
emergency response to Hurricane Harvey remained underway. As the hurricane and subsequent
flooding advanced from the Houston area eastward into the Beaumont region, emergency
responders needed to move as well. Rainfall from the storm flooded portions of Interstate 10,leaving eastbound Highway 90, which cut through the middle of the evacuation zone for the
Arkema Crosby incident, as the best route for transporting hurricane relief and rescue resources.

18.

Due to this constraint and the importance of transporting personnel and equipment to where they
were needed, Harris County officials kept eastbound Highway 90 open to traffic even while
enforcing the remainder of the evacuation zone. Emergency responders were also staged to block
the road if the contents of one of the refrigerated trailers began to combust.

19.

On Wednesday, August 30, 2017, just before midnight, two of the police officers assigned tomonitor the exclusion zone perimeter reported that they drove through a cloud of white smoke
coming from the Arkema Crosby facility as they drove west on Highway 90 to respond to a callrelated to flooding in the area. After they reported the white smoke cloud, the Unified Command
closed Highway 90.

20.

Following the report of the white smoke cloud, two members of the Crosby Volunteer Fire
Department were sent to the Arkema facility to assess the scene. Upon arrival at the site, these
responders did not see a white cloud or other signs of organic peroxide decomposition. The Unified
Command also reviewed telemetry data provided by Arkema including temperature readings withinsome of the trailers showing that the air temperatures in three of the refrigerated trailers were above
the estimated SADT. Three of the nine refrigerated trailers, however, could not provide this data.
Furthermore, those trailers sending data only measured the air temperature inside of the trailer andnot the temperature of the organic peroxide products so the readings did not necessarily mean thatthe organic peroxide contents were decomposing. Based on the need to keep eastbound Highway
90 open as long as possible and the visual confirmation that there was no decomposition occurring,
emergency responders reopened the highway.

21.

The police officers who drove through the white smoke cloud reported to other police officers that
their vehicle’s dash cam recorded the white cloud and that some type of release was occurring at thefacility. Three other police officers then drove their vehicles east on Highway 90 to check on theofficers and to review the dash cam footage. As these officers passed by the Arkema facility, theyalso reported driving through a white cloud of smoke coming from the facility.

22.

Shortly thereafter, all five police officers recognized they might have been exposed to chemicals by
driving through the cloud of white smoke coming from the Arkema Crosby facility. The
combination of their symptoms, and their desire to get prompt medical attention led the police
officers to drive west on Highway 90 toward the command post and medical aid to obtaintreatment.

12

CSB · Investigation Report23.

In all, five police officers in four police vehicles drove west down Highway 90 toward thecommand post. The officers called to request medical assistance when they reached thesouthwestern end of the exclusion zone. During this trip, the officers reported being exposed to a
black smoke cloud coming from the Arkema Crosby facility. By the time they reached thesouthwestern end of the exclusion zone, the officers reported experiencing nausea, headaches, sorethroats, and itchy watering eyes. Other emergency responders examined the police officers, whowere complaining of exposure to the smoke, and flushed the officers’ exposed skin with water.

24.

When the officers reached the forward command post they told the emergency responders what
they had experienced. Harris County emergency response officials then shut down travel in both
directions on Highway 90. Highway 90 was not reopened until the all-clear was sounded days
later. As the night progressed, organic peroxide products in one of the nine refrigerated trailers
continued to decompose and then caught on fire.

25.

The next day, Friday, September 1, 2017, at about 5:00 pm, two more refrigerated trailers ignited
and burned. At this point, the three refrigerated trailers that could not be moved to the high groundin the laydown area due to the high waters had all burned and the remaining six refrigerated trailers
located on higher ground had still not combusted. It is likely that the refrigeration units on thesetrailers were still operating, but with no way to check on the contents inside of the trailers and only
relying on telemetry data, the Unified Command could not safely remove the organic peroxide
contents.

26.

Residents who had been evacuated were still not allowed to reenter the 1.5-mile perimeter because
the six refrigerated trailers still had not combusted. Around this time many evacuees began toexpress concern over their inability to check on their homes and gather their belongings. As it
became clear that days or weeks might pass before the remaining trailers burned, the emergency
responders developed a plan to conduct a controlled burn of those trailers.

27.

On Sunday, September 3, 2017, emergency responders entered the Arkema Crosby site andconducted a controlled burn of the remaining six refrigerated trailers in order to end the evacuationand incident. Once the fires burned out, the emergency responders lifted the evacuation zone,
allowing residents to return to their homes. Finally, on September 4, 2017, the Unified Commandannounced the all-clear and opened Highway 90 to traffic.

1.2.
28.

KEY FINDINGS AND LESSONS
Organic peroxides are reactive chemicals that are inherently unstable. Because of this instability,
these reactive chemicals require special storage and handling precautions to prevent the organic
peroxides from decomposing and producing heat and byproducts. Organic peroxides continuallydecompose at a rate based on the temperature of the product. An important organic peroxide safety
property is the Self-Accelerating Decomposition Temperature or SADT. All of the organic
peroxides produced by Arkema must be stored at a temperature below their SADT to limit the rateof decomposition to a safe level. The first three refrigerated trailers burned in two separate fires at
the Arkema Crosby facility when the trailers lost refrigeration and the organic peroxide products
inside, which required low-temperature storage, decomposed and combusted. Companies need to
CSB · Investigation Report13ensure they have sufficient safeguards in place to maintain organic peroxide products below their
SADTs.
29.

Arkema had multiple safety systems in place to ensure that organic peroxide products were kept
cold and would not reach their SADTs. In Arkema’s process hazard analysis (PHA), the PHA teammembers identified the following layers of protection: redundant refrigeration systems in the Low
Temperature Warehouses; emergency generators to provide power in case a Low Temperature
Warehouse lost power; liquid nitrogen for alternative cooling; and refrigerated trailers to storeorganic peroxide temporarily. All of these layers of protection failed during Hurricane Harvey
because of flooding which was a common mode of failure. None of Arkema's safeguards used toaddress electrical power failure met company or industry standards for analyzing independent
protection layers for Harvey-level flooding. The same floodwater that caused the facility to loseelectrical power also compromised the backup emergency generators, the liquid nitrogen system,and the refrigerated trailers used to temporarily store and cool the organic peroxide products.
Companies need to ensure there are not common modes of failure in their layers of protection.

30.

Federal Emergency Management Agency (FEMA) flood insurance rate maps and flood insurance
studies provide important flood risk information. The Arkema Crosby facility was constructed
before any flood maps or studies of the area were developed. The first flood map for the area
encompassing the Arkema Crosby facility, found by the CSB investigation, was issued in 1985.
This map showed minimal flood risk for the facility. FEMA issued a significant revision to therelevant flood insurance rate map in 2007. This revision established that the entire Arkema Crosby
facility sits within a floodplain. Some portions of the facility are in the 100-year floodplain, and theremaining areas of the site are in the 500-year floodplain. Although a September 2016 report fromArkema’s insurer, FM Global, identified flood risks to the Crosby facility, including thesefloodplain designations, Arkema Crosby facility employees, other than a past facility manager,
appeared to be unaware of this information. Although Federal process safety regulations requirecompanies to compile relevant process safety information, the regulations do not specifically
identify flood insurance maps and related studies as required process safety information. The CSB
investigation revealed that other companies also might be unaware of the potential for flood risks tocreate process safety hazards at their facilities if flood-related information is not typically compiled
or assessed in required safety analyses.

31.

The Arkema team that performed the Low Temperature Warehouse PHA for the Crosby facility did
not document any flooding risk. Had the Arkema PHA assessed flooding, the limited industry
guidance on flooding would likely have been insufficient to provide specific or sufficiently
conservative level of action to protect against the hazards posed by the flooding during Hurricane
Harvey. Even without this assessment, however, the Crosby facility appears to have had sufficient
safeguards in place to prevent loss of refrigeration in the Low Temperature Warehouses for a 100year flooding event.

32.

Industry safety guidance for companies on how to address flood hazards was available from several
different sources, including the Center for Chemical Process Safety (CCPS) and FEMA. This
guidance, however, is either too generic or does not require sufficiently conservative precautions tohave helped Arkema prevent this incident. For example, this guidance does not require elevating

14

CSB · Investigation Reportcritical equipment to heights that would have prevented Hurricane Harvey-level floodwater fromdisabling safety systems at the Arkema Crosby facility. Given this type of shortcoming, morerobust industry guidance is needed to help hazardous chemical facilities better prepare for extreme
weather events, such as flooding, hurricanes, snowstorms, tornadoes, or droughts.
33.

Although the Arkema Crosby facility had a history of flooding over the past 40 years, long-term
employees could not recall floodwater occurring higher than two feet before Hurricane Harvey. As
a result, Arkema did not consider flooding of its safety systems to be a credible risk. When
determining the risk of 100-year or 500-year flooding events, however, relying on the experience ofindividual employees is insufficient to determine the risk level. For example, long-term employees
at the Arkema Crosby facility recalled Tropical Storm Allison in 2001 as the previous high-water
benchmark for flooding at the site. In contrast, flood records suggest that rainfall from Hurricane
Rosa in 1994, and even rainfall from an unnamed storm in 2015, produced more significant
flooding at the Crosby site than did Allison. Hurricane Harvey produced over five feet of flooding
in some areas of the Arkema Crosby facility. Companies should develop systems to retain key
incident summary information that better document facility risks based on historical external
events. These external events, such as flooding, have a low probability of occurrence but canthreaten severe health and safety consequences.

34.

Flooding from Hurricane Harvey extended above the 500-year flood plain elevation. Although thisflood level was unprecedented in the area, extreme flooding had been occurring with regularity.
Since 1994, the water gauge closest to the Arkema Crosby facility recorded three 100-year flooding
events, one of which came close to the 500-year flood criteria. In recent years, flooding fromextreme rainfall events has increased and according to a 2015 EPA report, this trend is projected tocontinue, increasing the flood risk in many parts of the U.S. This EPA report also provides future
projections that show Texas as leading the nation in the potential for flood-related damage.

35.

Highway 90, which bisected the evacuation zone, remained open to eastbound traffic even after
emergency response officials established the evacuation zone. Although admittedly a difficult
decision for the Unified Command, keeping Highway 90 open for use in moving people andresources in relation to the eastward trajectory of Hurricane Harvey allowed emergency responders
to travel within close proximity to the plant even after the first fire began. But once a report came inthat the situation at the Crosby facility became less stable and that decomposition might beoccurring, emergency response officials should have closed Highway 90 and established alternativeroutes. As a result of this decision, at least 21 people were exposed to decomposition products andsmoke from the burning refrigerated trailer and organic peroxides. Hurricane Harvey emergency
responders had limited options available to facilitate critical transportation other than Highway 90.
The telemetry data coming from the trailers containing the organic peroxide products showed nosigns of combustion; however, the police officers reported a chemical release after driving into thewhite smoke cloud, smelling the vapor, and experiencing exposure symptoms. In an emergency,
data are frequently incomplete and can even be contradictory, so emergency responders must be asconservative as practicable so that they can protect both themselves and the public.

36.

In the United Kingdom, the Environment Agency published guidance to help regulated facilities
conduct flood planning. This flood preparation guidance recommends that companies should be

CSB · Investigation Report15

aware of their flood risks at all facilities, obtain flood modeling results, prepare a flood plan, andimprove their flood resilience. The guidance also recommends that companies should be able toimplement their flood plan before flooding and that each plan include steps to protect workers,
safeguard hazardous processes, and secure hazardous materials. Of relevance to the Arkema
Crosby incident, the Environment Agency flood preparation guidance specifically discusses
safeguarding chemical products that are vulnerable to risks posed by floodwater and proactively
protecting key utilities, such as electrical power and liquid nitrogen.

1.3.

GUIDANCE TO INDUSTRY

37.

In response to the incident, Arkema commissioned a site elevation survey for its Crosby facility tounderstand the elevation for all relevant points at the facility as well as a hydrological study tounderstand the likely flooding conditions during extreme weather events, such as hurricanes.
Arkema will be able to use this data to evaluate the risks for a number of floodwater severity levels
to help prevent future loss of refrigeration leading to organic peroxide product decomposition.

38.

Reflecting the positive actions taken by Arkema post-incident, the CSB provides guidance tocompanies with chemical manufacturing, handling, or storage facilities in areas that are susceptible
to extreme weather events, such as flooding.

1.4.
39.

16

•

Such facilities should perform an analysis to determine their susceptibility to extreme
weather events. Companies should compile key safety information such as flood maps
within their process safety information programs. This important safety information shouldbe evaluated to determine whether any portions of their facilities are located within the 100year or 500-year flood plain. In addition, companies should assess seismic hazard maps todetermine the risk of earthquakes and consider the risk of other extreme weather such as
high-wind events.

•

Companies should evaluate risk assessments and the adequacy of relevant safeguards byapplying facility process safety management programs, such as process hazard analyses or
facility siting programs. Facilities should strive to apply a sufficiently conservative risk
management approach when evaluating and mitigating the potential effects of extreme
weather scenarios.

•

Facilities should ensure that critical safeguards and equipment are not susceptible tocommon mode failures. For flooding scenarios, independent layers of protection should beavailable if floodwater heights reach the facility.

SUMMARY OF RECOMMENDATIONSThis report provides details of the incident and its causes, provides key safety lessons, andcommunicates industry safety guidance with the goal of preventing a similar incident. As a resultof its investigation, the CSB is issuing safety recommendations to management at the Arkema
Crosby facility, Arkema Inc., the American Institute of Chemical Engineers Center for Chemical
CSB · Investigation ReportProcess Safety, and to officials of Harris County, Texas. The CSB urges companies to review the
key safety lessons and safety guidance contained in this document for application at their facilities
and to evaluate their existing process safety management practices and equipment design forpotential improvements.

CSB · Investigation Report17

2. BACKGROUND INFORMATION ON ARKEMA CROSBY OPERATIONS
40.

The Arkema Group is a global chemical manufacturer reporting annual sales of $9 billion,
operating in nearly 50 countries with about 20,000 employees world-wide [4]. a The company wasformed during the reorganization of Total’s chemicals branch in 2004 [5].

41.

In North America, the Arkema Group operates under its subsidiary Arkema Inc. (“Arkema”) with
headquarters in King of Prussia (KOP), Pennsylvania [6]. This regional subsidiary employs about
6,000 people and operates 48 sites in the United States, Canada, Mexico, and Brazil [6].

42.

Arkema produces numerous chemicals, including a variety of organic peroxide products that thecompany refers to as Luperox® organic peroxides. b Shipping regulations prohibit transporting
many of these organic peroxide products by air. As a result, the global Arkema Group
manufactures these organic peroxide products locally in nine different countries [7]. c Arkema Inc.,a subsidiary, manufactures organic peroxide products in three different countries, the United States,
Mexico, and Brazil.

43.

In the United States, Arkema manufactures organic peroxide products at the following threelocations:

2.1.
44.

•

Crosby, Texas (“Arkema Crosby”) [8];•Franklin, Virginia [9]; and•Geneseo, New York [10].

ORGANIC PEROXIDESThe Arkema facility in Crosby, Texas employs about 50 people and produces about 30 different
types of organic peroxide products that the company markets to polymer manufacturers [11, p. 2].
The organic peroxide products are used to develop a variety of consumer products such as solid
surface countertops, polystyrene cups and plates, polyvinyl chloride (PVC) plates and cups, and inautomotive components such as hoses, gaskets, and headlight assemblies [12]. Arkema’saSales figure based on the €7.5 billion figure reported by Arkema and the September 2017 exchange rate of $1.2 per euro [4].
“Organic peroxides are initiators used in a variety of fields including commodity polymers (reaction initiators for low-density
polyethylene, PVC and polystyrene), acrylic polymers, unsaturated polyesters and rubber crosslinking. [Arkema Group internal
estimates show] that it ranks number two worldwide in this sector. Its main competitors are AkzoNobel and United Initiators[214, p. 24].”c
Arkema manufactures Luperox organic peroxide products in the United States, Mexico, Brazil, Germany, Italy, India, China,
Korea, and Japan (joint venture) [7].
b18

CSB · Investigation Reportpredecessor purchased the Crosby plant property in 1960 and constructed its chemical
manufacturing processes in the 1960s. a, b
45.

Organic peroxides are unstable chemicals, making them commercially important as polymerization
initiators and curing agents [13, p. 219]. Because of this instability, organic peroxides require
special storage and handling precautions [13, p. 219]. The inherent instability of organic peroxides
stems from their oxygen-oxygen (-O-O-) bond, known as a peroxy functional group [14, p. 3]. c
This peroxy functional group decomposes with heat producing commercially desirable chemical
reactions, in addition to heat and byproducts [14, p. 3]. d

46.

Organic peroxides continually decompose at a rate that depends on their temperature [13, p. 219].
Each organic peroxide decomposes at a different rate, and some of them need to remain at a lowtemperature in cold storage for quality or safety reasons [14, p. 3], [11, p. 2], [15, p. 71]. e

47.

When an organic peroxide decomposes it generates heat and when the heat gained exceeds the rateof heat loss to the surroundings, the temperature of the organic peroxide increases and canaccelerate the decomposition of the remaining peroxide [13, p. 219]. As the temperature increases,
this reaction can result in a self-accelerating decomposition runaway reaction [13, p. 219], [16, p.
4]. f

48.

An important organic peroxide safety property is the Self-Accelerating Decomposition Temperature(SADT) – the lowest temperature at which an organic peroxide product (in its transport packaging)exhibits self-accelerating decomposition [17, p. 7]. g, h Organic peroxides still decompose attemperatures below the SADT, but this decomposition is slow enough that it does not lead to selfacceleration [17, p. 8]. Figure 2 shows an Arkema safety video image excerpt of an organic
peroxide violently reacting from self-reactive decomposition [18]. iaArkema expanded its chemical production and warehouse facilities over the years.
Arkema records show the Crosby site was originally owned by Wallace & Tiernan. In 1969 Wallace & Tiernan merged with
Pennsalt, becoming Pennwalt. The Crosby facility remained with Pennwalt until it was acquired by Elf Aquitaine in 1990. In
2004, when Arkema was formed, the site became part of Arkema Inc.
c
A functional group is a group of atoms that give molecules similar properties. The Functional Group Explained [215].
d
AkzoNobel published several videos showing how industry uses its organic peroxides, including Crosslinking Polymers with
Organic Peroxides [175], Free Radical Polymerization [174], and Unsaturated Polyester Resin Curing [173].
e
Organic peroxide decomposition includes the production of vapor (gas). Some of this vapor may be flammable, but unlike
hydrogen peroxide decomposition, organic peroxides do not generally release oxygen [14, p. 17].
f
A thermal runaway is “An exothermic reaction can lead to thermal runaway, which begins when the heat produced by thereaction exceeds the heat removed. The surplus heat raises the temperature of the reaction mass, which causes the rate ofreaction to increase. This in turn accelerates the rate of heat production [176, p. 1].”g
The SADT is the lowest temperature at which a tested organic peroxide in its packaging will exhibit self-accelerating
decomposition within one week. Thus, the SADT depends on both the organic peroxide formulation and its packaging [14, p.
16].
h“The SADT is the lowest temperature at which product in a typical package will undergo a self-accelerating decomposition.
The reaction can be violent, usually rupturing the package, dispersing peroxide, liquid and gaseous decomposition products
considerable distances. The heat generated might autoignite flammable vapors. There is generally a period of time after the
SADT is reached and before the decomposition becomes violent. The length of time depends upon how much the SADT is
exceeded, which can greatly accelerate the decomposition [153, p. 1].”i
The original video is available on the Arkema website [236].
b

CSB · Investigation Report

19Figure 2. Organic Peroxide Decomposition. The image on the left is from a video showing anorganic peroxide container under self-accelerating decomposition conditions [18]. The graphic on
the right is an Arkema illustration showing that organic peroxide products are safe below the“Recommended Storage Temperature” and that the uncontrolled decomposition reaction that
occurs above the SADT [11, p. 3].

49.

2.2.
50.

At the time of the incident, the Arkema Crosby facility stored about 367,000 pounds of organic
peroxide products that required refrigeration in the Low Temperature Warehouses. These products
included 11 organic peroxide products requiring refrigeration because their SADT’s ranged from 23
to 113 °F. a These organic peroxide products are hazardous, but not the most hazardous class oforganic peroxides based on U.S. Department of Transportation (DOT) regulations. b Although an
explosion of these organic peroxide products is possible, in their final product packaging a fire is
the more probable hazard in a potential heating scenario, such as prolonged loss of refrigeration[19]. c Additional organic peroxide information is provided in Appendix B.

ORGANIC PEROXIDE STORAGE BUILDINGSThe Arkema Crosby facility has nine organic peroxide storage buildings. Seven of these are cold
storage buildings, referred to as Low Temperature Warehouses that Arkema maintains between -20°F and 0 °F depending on the requirements of organic peroxide(s) stored inside (Figure 3). One
organic peroxide product storage building operates at ambient temperature. The final organic
peroxide storage building is the largest at the Arkema Crosby facility and has several internal
compartments that the company maintains between 40 °F and ambient temperature.

aArkema’s required storage temperature for each organic peroxide product is well below the SADT.
49 C.F.R. § 173.128 (b) (2004).
c
Safety Data Sheets for organic peroxide Types C through F use a flame pictogram and hazard statement that “heating may cause
fire.” Type A and B organic peroxides have potential explosion hazards [19].
b

20

CSB · Investigation ReportFigure 3. Crosby Low Temperature Warehouses. Three of the seven Low Temperature
Warehouses at the Arkema Crosby facility are shown in this photograph. (Source: CSB Photo)

2.3.
51.

REFRIGERATION
Each of the seven Low Temperature Warehouses is cooled using an electrically-poweredrefrigeration system (Figure 4). Each Low Temperature Warehouse is equipped with at least two
refrigeration systems, with one serving as a backup. Because refrigeration is needed to maintainsome of Arkema’s organic peroxide below the self-accelerating decomposition temperature, thecompany’s procedures stress the importance of taking prompt action when refrigeration equipment
problems arise.

CSB · Investigation Report

21Figure 4. Typical Refrigeration Equipment Used to Keep the Low Temperature Warehouses Cold at
the Arkema Crosby Facility. The photo on the left shows refrigeration evaporator equipment used
to remove heat from the inside of a Low Temperature Warehouse. The photo on the right shows
refrigeration condensing equipment, that removes heat from the refrigerant and also showselectrical equipment for the refrigeration system and other electrically powered equipment for thebuilding, such as lighting. a (Source: CSB Photo)

52.

2.4.
53.

a

Arkema’s procedures detail actions to take in response to a variety of scenarios that might elevate
the temperature in one of the Low Temperature Warehouses. Identified actions include:•

Expediting maintenance for refrigeration equipment issues;•

Relocating the organic peroxide products to another Low Temperature Warehouse;•

Starting up the emergency generators to supply backup electrical power;•

Using liquid nitrogen as an alternative source of refrigeration; and•Moving the organic peroxide products to refrigerated truck trailers.

EMERGENCY GENERATORS
Seven diesel-powered emergency generators supply a backup source of electricity to buildings andequipment at the Arkema Crosby facility (Figure 5). Two of the seven emergency generators
provide backup power to Arkema’s Low Temperature Warehouses.

See HOW IT WORKS: Refrigerators for a basic explanation of refrigeration [208].

22

CSB · Investigation ReportFigure 5. One of Seven Emergency Generators at the Arkema Crosby Facility. Generator 21-GN-1 is
one of the two generators providing emergency electrical power to Arkema’s seven Low
Temperature Warehouses. The bottom of the generator (top of the concrete foundation) is about
two feet above the ground. (Source: CSB Photo)

2.5.
54.

LIQUID NITROGEN SYSTEM
The Arkema Crosby facility uses a liquid nitrogen system to deliver a backup source of emergency
cooling for its Low Temperature Warehouses (Figure 6). If a significant refrigeration problem
occurs, such as loss of power and backup power, workers can connect short hoses and then open
valves to inject liquid nitrogen into any one of the organic peroxide Low Temperature Warehouses
to supply a source of refrigeration that is independent of electricity. Each of the Low Temperature
Warehouses is equipped with dedicated piping for liquid nitrogen. Normally this piping is capped
and the system is locked out to prevent inadvertent use. In addition to being extremely cold,
injected liquid nitrogen will dilute the oxygen concentration, creating an asphyxiation hazard toworkers.

CSB · Investigation Report

23Figure 6. Liquid Nitrogen Tank at the Arkema Crosby Facility. Among other uses, this tank holds up
to 40,000 pounds of liquid nitrogen that can be injected into each of the organic peroxide Low
Temperature Warehouses to provide a backup refrigeration source. (Source: CSB Photo)

2.6.
55.

24

REFRIGERATED TRAILERS
As a final backup for scenarios causing elevated temperature in one of the Low Temperature
Warehouses, organic peroxide products can be relocated to one or more portable refrigerated truck
trailers (Figure 7). Arkema uses these refrigerated trailers primarily for shipping organic peroxide
products to customers; however, Arkema procedures allow the use of these trailers in emergency
situations or while making repairs to Low Temperature Warehouse refrigeration systems. The fueltank for these refrigerated trailers is located under the container that powers the refrigeration unit.
With a full tank, the refrigerated trailers can normally maintain appropriate cold conditions formore than a week.

CSB · Investigation ReportFigure 7. Refrigerated Truck Trailer. Arkema used about a dozen refrigerated truck trailers like this
one used to ship organic peroxide products to customers and to provide a temporary storage
location if the refrigeration at one or more of the Low Temperature Warehouses could not be
maintained. (Source: CSB Photo)

2.7.
56.

PRODUCT TOTES
Organic peroxide products that require low-temperature storage are generally packaged in either
one or five-gallon plastic containers, or totes. Customers frequently use small quantities of organic
peroxides so such totes are convenient for customers. These organic peroxide totes are stacked
onto pallets and shrink-wrapped, enabling workers to move the products more easily around thefacility and providing stability during shipping (Figure 8).

CSB · Investigation Report25

Figure 8. Stacked Organic Peroxide Totes. This example shows shrink-wrapped five-gallon
containers on pallets. (Source: Arkema Photo)

26

CSB · Investigation Report

3. INCIDENT DESCRIPTION57.

The National Hurricane Center produced a report summarizing Hurricane Harvey a and the heavy
rainfall it produced. Hurricane Harvey was a Category 4 storm before making landfall along the
middle Texas coast [20, p. 1]. The storm stalled, “dropping historic amounts of rainfall of morethan 60 inches over southeastern Texas [20, p. 1].” The path of the hurricane is shown in Figure 9
below. As can be seen the hurricane made landfall twice and stayed in the vicinity of southeast
Texas for an extended duration, contributing to the large amount of rainfall in the area.

Figure 9. Path of Hurricane Harvey. The approximate location of the Arkema Crosby facility isshown by the red circle. (Source: Cooperative Institute for Meteorological Satellite Studies [21].)(Image Modified by CSB)58.

The National Hurricane Center Tropical Cyclone Report on Hurricane Harvey described thedamage as follows:
These rains caused catastrophic flooding, and Harvey is the second-mostcostly hurricane in U.S. history [$125 billion], b after accounting for
inflation, behind only Katrina (2005). At least 68 people died from thea

In April 2018, the World Meteorological Organization retired Harvey from its list of storm names. Storm names are retired
when they are so destructive that future use of the name would be insensitive. Since 1953, 86 storm names have been retired[234].
b
The National Hurricane Center report used damage estimates developed by the National Oceanic and Atmospheric
Administration (NOAA) [20, p. 9]. See Billion - Dollar Weather and Climate Disasters: Table of Events [224].

CSB · Investigation Report27

direct effects of the storm in Texas, the largest number of direct deaths
from a tropical cyclone in that state since 1919. [20, p. 1].
59.

With respect to rainfall, the report observed, “Harvey was the most significant tropical cyclone
rainfall event in United States history, both in scope and peak rainfall amounts, since reliable
rainfall records began around the 1880s [20, p. 6].” The report also identified the storm as forcing
40,000 people to evacuate or seek refuge in shelters; flooded over 300,000 structures; and damaged
about 500,000 cars [20, p. 9]. Figure 10 and Figure 11 show the areas that were most affected by
the precipitation from the hurricane.

Figure 10. Total Precipitation from Hurricane Harvey in the Southeast Texas Region. The Arkema
Crosby facility approximate location is shown by the red circle [22]. (Image Modified by CSB)28

CSB · Investigation ReportFigure 11. NOAA's National Weather Service Map Showing Rainfall Exceedance Annual
Probabilities During Hurricane Harvey in Southeast Texas. The different colors show the probability
in a year for the area to experience the amount of rain demonstrated by Harvey [23], [24].

60.

As shown in Table 1, in the days leading up to Hurricane Harvey, the rainfall predictions increased
even after the storm made landfall.

CSB · Investigation Report29

Table 1. Predicted Rainfall for the Houston Area During Hurricane Harvey.

Date
Thursday, August 24
Friday, August 25
Saturday, August 26
Sunday, August 27
61.

Southeast Texas Total Predicted Rainfall
12-30 inches
15-35 inches
15-40 inches
15-50 inches

Ultimately, a rain gauge at the Arkema Crosby facility recorded more than 39 inches of rainfall
during Hurricane Harvey (Figure 12).

Figure 12. Arkema Crosby Facility Rain Gauge Data. The Arkema site recorded more than 39 inchesof rainfall during the days when Hurricane Harvey affected the area.

3.1.
62.

THURSDAY, AUGUST 24, 2017
After traveling through the Gulf of Mexico for over 10 days, it became clear that Hurricane Harvey
would affect the middle and upper Texas coast and likely stall over the southeast Texas region [1].
At 10:00 am central daylight time on August 24, 2017, the National Hurricane Center update
warned that Hurricane Harvey was strengthening and predicted extreme flooding from the storm.
The update stated:
Harvey has intensified quickly this morning, and is now forecast to be amajor hurricane at landfall, bringing life-threatening storm surge, rainfall,
and wind hazards to portions of the Texas coast. Preparations to protect
life and property should be completed by tonight, as tropical-storm-force
winds will first arrive in the hurricane and storm surge warning areas on
Friday [2].

30

CSB · Investigation ReportLife-threatening flooding is expected across much of the Texas coast fromheavy rainfall of 12 to 20 inches, with isolated amounts as high as 30
inches, from Friday through early next week [2].
63.

Anticipating that Hurricane Harvey would make landfall the next day (Friday, August 25, 2017),
personnel at the Arkema Crosby facility began to prepare for the storm. The Arkema Crosby
facility had a hurricane plan detailing how the site planned to protect workers and property before,
during, and after a hurricane. The team assigned to implement the plan started meeting at the
beginning of the hurricane season (June 1) and monitored storms forming in, or moving into, theGulf of Mexico. The Arkema Crosby facility communicated and worked with corporate staff about
potential storms to determine when to activate the ride-out crew, which is composed of staff
members assigned to remain at the facility for the duration of a hurricane. The ride-out crew is
responsible for the safety of the plant during the hurricane and for monitoring for changing
conditions. The crew is composed of the following facility personnel:•

Management (two);•

Operators (four);•Refrigeration specialist (one);•

Maintenance (three); and•Mechanic/Electrician (two).

64.

On Thursday, Arkema personnel decided that they needed to ready the plant in case the hurricane
would affect the Crosby facility. The facility personnel had been monitoring the progress of
Hurricane Harvey for a few days and were prepared to implement the Hurricane Preparedness Plan.
Based on local weather forecasts, Arkema facility management personnel expected the hurricane
would pass south of the Crosby facility and anticipated 10 to 15 inches of rain at the facility overthe duration of the hurricane. The facility leadership team met to discuss the best way to shut down
the facility and prepare for the hurricane in case the facility was seriously affected.

65.

By 10:00 pm central daylight time on Thursday, August 24, 2017, the National Hurricane Center
projected “devastating and life-threatening flooding across the middle and upper Texas coast fromheavy rainfall of 15 to 25 inches, with isolated amounts as high as 35 inches [25].” By the end ofthat same day, the weather forecast was calling for 15 to 18 inches of rain at Crosby, leading theArkema Crosby management team to initiate its operational moves to prepare for the event.

66.

On the basis of their previous experience, Arkema Crosby facility employees knew that this level ofrain was enough to flood roads and likely would necessitate activating the ride-out crew because
workers would have difficulty getting to or leaving the facility. The Crosby facility personnel
anticipated that 40 inches of rainfall would generate one to two feet of floodwater, which would
make it difficult to move between locations at the facility but would not affect the safety systems.
The Arkema logistics group called suppliers and customers to let them know that the facility would
not need raw materials and production would likely be interrupted.
CSB · Investigation Report

31

3.2.

FRIDAY, AUGUST 25, 201767.

By the morning of Friday, August 25, 2017, the weather forecast for the Crosby facility projected
15 to 25 inches of rain accumulation, with isolated amounts as high as 35 inches over the durationof the hurricane [26]. The Federal Emergency Management Agency (FEMA) worked with the
Texas Division of Emergency Management and other agencies to pre-position supplies andpersonnel in place to manage the hurricane’s effects [27]. By the end of the day, FEMA formallydeclared the situation a “major disaster” [28].

68.

The forecast calling for increased rainfall made it clear that flooding of local roads was likely andthat the 12-member ride-out crew should be activated. There was little concern, however, about thefacility losing power or any potential effects on the refrigerated organic peroxide products.

69.

At 2:00 pm on Friday, August 25, 2017, Hurricane Harvey became a Category 3 hurricane, andthen early Friday evening evolved to a Category 4 hurricane with sustained winds reaching 130
miles per hour [1]. Throughout the day, the outer bands of the storm began to produce rainfall at
the Crosby facility as Harvey approached the coast (Figure 13).

Figure 13. Hourly Rainfall on Friday, August 25, 2017 During Hurricane Harvey. Cedar Bayou gauge
station 1740, which is about 2.5 miles northeast of the Arkema Crosby facility, measured hourly
rainfall during Hurricane Harvey as shown in this graph for August 25 [29].

70.

32

Arkema halted production at the Crosby facility due to the impending arrival of Hurricane Harvey.
Plant personnel started hurricane preparations, including:•Securing loose materials, such as scaffolding and empty product totes, so that they could notblow or float away in the storm;•

Elevating portable equipment such as compressors to keep them out of floodwater;•

Completing process shutdown including emptying and washing process equipment;

CSB · Investigation Report

71.

3.3.
72.

•

Bringing storm equipment onsite, including an off-road forklift and a boat;•

Staging equipment, such as pumps, hoses, and sandbags;•

Filling diesel tanks for backup generators and refrigerated trailers;•

Ensuring that the liquid nitrogen tank was full;•

Reviewing storm scenarios and corrective actions with members of the ride-out crew; and•Reducing the level in waste water treatment equipment in preparation for the heavy rain.

On Friday, only about an inch of rain fell on the Arkema Crosby facility but the storm was
beginning to worsen (Figure 13) [29]. At around 10:00 pm, the eye of Hurricane Harvey madelandfall about 30 miles northeast of Corpus Christi, Texas on the southern Texas Gulf Coast [1].
As the storm progressed into Texas, the National Hurricane Center forecasted “catastrophic andlife-threatening flooding” across the middle and upper Texas coast and from 15 to 30 inches ofheavy rain, with isolated totals as high as 40 inches [30].

SATURDAY, AUGUST 26, 2017
At 10:00 am, the forecast from the National Hurricane Center remained unchanged, with aprediction of heavy rainfall of 15 to 30 inches, and isolated amounts as high as 40 inches [31]. As
the rain continued to fall in the Houston area, flooding began at the Crosby facility and the waterlevel rose in the Cedar Bayou watershed (where the Crosby facility is located) by about 13 feet
(Figure 14).

CSB · Investigation Report33

Figure 14. Gauge Station 1740 Graphic Showing Cedar Bayou Stream Elevation During Hurricane
Harvey. The water level steadily rose for most of the day on Saturday, August 26, 2017 [29]. a, b

73.

Once Arkema shut down the facility and activated the ride-out crew, the 12 members of the Crosby
ride-out crew remained at the Arkema site for the duration of the storm. The incident then evolved
into the next phase with the ride-out crew attempting to move the organic peroxide products to safe
locations at the Crosby facility. As the waters rose at the Arkema facility, the ride-out crew
monitored the condition of the plant, focusing on the plant utilities and the wastewater treatment
system to ensure that they could handle the increased demand. The ride-out crew performed
surveillance trips around the facility to ensure that no loose items remained that could blow or float
away and to check on the condition of the facility. As the day progressed, it became apparent that if
the water continued to rise, the ride-out crew would need to proactively de-energize electricalequipment, including transformers for individual building power, so that nothing short-circuited.

74.

The ride-out crew analyzed the susceptibility to flooding of the electrical equipment within thefacility primarily by determining how close to the ground the electrical equipment was located.
Water reaching the 480-volt transformers on the Low Temperature Warehouses was a primaryconcern as failure of these devices could either damage property or electrocute nearby workers.
Once the ride-out crew members decided that a Low Temperature Warehouse (or any building) was
at risk of rising floodwater reaching susceptible electrical equipment, they manually switched off
the power to the entire building before the water could reach the electrical equipment.

75.

On Saturday evening, the storm knocked out the plant’s phone system, but the ride-out crew still
had cell phone service. Steady rainfall throughout the day increased flooding at the facility causing
standing water in the area around the Low Temperature Warehouses. The ride-out crew members
recognized that if the floodwater continued to rise, they would need to move the organic peroxideaBottom of channel (BOC) is the elevation at a bayou’s lowest point. Top of bank (TOB) refers to the height of the banks of abayou at the location where water could overflow during a heavy rain event. To determine the depth of a particular waterway,
subtract the bottom of channel from the top of bank measurement [139].
b
For Cedar Bayou at Highway 90, top of bank is 53.4 feet and bottom of channel is 36.09 feet [29].

34

CSB · Investigation Reportproducts from some of the Low Temperature Warehouses as the buildings lost power andconsequently their refrigeration capability. The ride-out crew, however, still thought that the event
would be manageable and that the hurricane would only minimally affect facility operations.
76.

Arkema corporate personnel activated the corporate crisis team to help with the response to theheavy rainfall at Arkema Texas sites in the path of the storm. The crisis team provides support andcoordinates communications during any type of crisis event. Although the crisis team members
were meeting at this point, they still anticipated that the ride-out crew at Crosby (as well as ride-out
crews at the other Arkema facilities in the region) could prevent any type of release or incident attheir facility as long as the floodwater stopped rising, which the corporate crisis team anticipatedhappening at any time.

77.

The National Hurricane Center update at 10:00 pm called for an additional 15 to 25 inches ofrainfall, with isolated totals of 40 inches through August 31, 2017 [32]. The key message included
a warning that “life-threatening” flood hazards would continue over much of southeastern Texas[32]. By the end of Saturday, August 26, 2017, about five inches of rain fell near the Arkema
Crosby facility (Figure 15) [29].

Figure 15. Hourly Rainfall on Saturday, August 26, 2017 During Hurricane Harvey. The Cedar Bayougauge station 1740 measured hourly rainfall during Hurricane Harvey, as shown in this graph forAugust 26 [29].

78.

Rain continued to fall, and the floodwater level at the Arkema Crosby facility continued to rise as
Hurricane Harvey stalled over southeastern Texas. The rate of increase in the water level began toaccelerate at the facility as Harvey continued to pour unprecedented amounts of rain in southeastern
Texas and as the downstream system water level continued to rise (Figure 14). The ride-out crew
members, however, monitored weather forecasts that predicted up to 30 inches of rainfall, which
the ride-out crew perceived to be manageable and not likely to be a threat to the facility, including
the Low Temperature Warehouses. In fact, the ride-out crew management sent an email aroundnoon that day to discuss a plan to deactivate the ride-out crew and begin normal staffing andoperation over the coming days. By Saturday night the storm did not end as expected, and with

CSB · Investigation Report35continually rising floodwater, the management team shifted its operational decision-making
strategy by adopting a day-to-day approach.

3.4.

SUNDAY, AUGUST 27, 201779.

The National Hurricane Center’s update at 10:00 am reported, “Harvey continues to meander oversoutheastern Texas, where it is producing catastrophic and life-threatening flooding rainfall [3].”The update also predicted an additional 15 to 25 inches of rain over the next several days, withisolated storm totals of 50 inches [3]. The key message warned people not to travel unlessnecessary for their safety [3].

80.

Significant flooding occurred early on Sunday and the ride-out crew members preemptively shut
down power to several of the Low Temperature Warehouses before the rising water reachedelectrical equipment. Figure 16 shows a Google Earth overview image of the Crosby facility. In
general, the bottom left (southwest) corner of the overview is lower ground, and higher ground istowards the top right (northeast). By 2:00 pm, parts of the facility had four feet of standing water.
As the water rose, it affected operation of the Low Temperature Warehouses (labeled 1 through 7 inFigure 16) from left to right in the figure, which is largely the order in which the ride-out crew shut
down the power to the warehouses and moved the organic peroxide products from the warehouses
to the refrigerated trailers.

36

CSB · Investigation ReportFigure 16. Pre-Hurricane Harvey Google Earth Overview of the Arkema Crosby Facility. This layout
shows the location of the main facility components (but the numbering of the buildings and thegenerators is not representative of the actual building or equipment numbers). (Image Modified by
CSB)

81.

The Arkema Crosby facility served as a local distribution center by providing low-temperatureorganic peroxide storage for a number of other Arkema organic peroxide manufacturing facilities.
As a central distribution hub, the site housed 11 refrigerated trailers that could serve as backup
storage containers. A number of the refrigerated trailers can be seen in Figure 16 next to Low
Temperature Warehouse 2.

82.

As workers turned off power to the Low Temperature Warehouses due to the rising water level(Figure 17), the ride-out crew moved organic peroxide products from six of the seven Low
Temperature Warehouses to other Low Temperature Warehouses, or to one of the 11 refrigerated
trailers located onsite. By early Sunday afternoon, workers had shut down three of the Low
Temperature Warehouses. Low Temperature Warehouse 1 was the first to be manually shut downwhen floodwater threatened to reach its electrical components. Workers next manually shut down
Low Temperature Warehouse 2 and Low Temperature Warehouse 3 and moved their organic
peroxide inventories to other locations. The ride-out crew used forklifts (Figure 18) to moveapproximately 20 pallets of organic peroxide products from these three Low Temperature
Warehouses into two refrigerated trailers, which were then moved to the laydown area. a After these
initial three Low Temperature Warehouses were emptied, the ride-out crew sent an update stating,a

The Crosby site had two semi-trailer trucks (referred to as “yard mules”) that workers used to move the refrigerated trailers
within the facility.

CSB · Investigation Report37

“Site does not think it is likely to lose cooling on another warehouse, but if that were to happen they
may not have enough [refrigerated trailers] to store [organic peroxide].” The ride-out crew believedthat the floodwater level would soon begin to recede, but it kept rising. More Low Temperature
Warehouses lost power and workers continued moving the organic peroxide products to otherlocations.

Figure 17. Air Conditioning Units Behind One of the Low Temperature Warehouses. The final
floodwater level is approximated by the red lines on the air conditioning equipment at the Arkema
Crosby facility. (Source: CSB Photo)

38

CSB · Investigation ReportFigure 18. Forklift Used by the Ride-out Crew. Ride-out crew members used the forklift shown inthis image to move organic peroxide pallets from the storage buildings after they turned off power
to the buildings because of the rising floodwater. (Source: Arkema Photo)83.

The ride-out crew shut off power not only to the Low Temperature Warehouses but also to otherbuildings at the plant as the floodwater level rose. As they cut power to these additional buildings,
the ride-out crew members lost their capability to remotely monitor some systems, such as thewastewater treatment facility. As a result, the ride-out crew began manually recording critical plantdata every hour, increasing their exposure to the hazardous weather and the overall workload on the
12-member crew.

84.

The rising floodwater level soon prompted workers to turn off power to the plant’s water supply
and fire water suppression pumps. The rising floodwater level also reached some of the backup
generators causing the ride-out crew to take them offline, including the generator (Figure 19) thatprovided backup power to Low Temperature Warehouses 1, 2, and 3 in Figure 16, to ensure crew
member safety. The Low Temperature Warehouses that had already been manually powered downby the ride-out crew no longer needed these backup generators.

CSB · Investigation Report

39Figure 19. One of the Emergency Generators Providing Backup Electricity to the Low Temperature
Warehouses. The photo on the left shows floodwater covering the bottom half of the generator(yellow oval) on Tuesday August 29, 2017. The post-incident photo on the right shows the samegenerator. (Source: Arkema Photo (left) Modified by CSB, CSB Photo (right))

85.

As the rising floodwater level began making it difficult for vehicles to move around the facility, theride-out crew members drove their personal vehicles to high ground to avoid the flooding.

86.

As discussed previously, a tank of liquid nitrogen served as one of Arkema’s safeguards for loss of
refrigeration or loss of electrical power to the Low Temperature Warehouse. Workers can injectliquid nitrogen directly into a cold storage building to reduce its temperature. On Sunday, when thereal threat of losing all power plantwide became clear, the ride-out crew decided to ensure theavailability of the nitrogen system. The liquid nitrogen piping system allowed nitrogen to be
injected into each Low Temperature Warehouse, one at a time if needed. The rising floodwatercompromised this system, however, by beginning to submerge the piping system. A member of theride-out crew called in a plant supervisor whose personal vehicle had a lifted chassis and large tires
that could still travel onto the Arkema Crosby site. The plant supervisor arrived onsite and added afoot-long extension (Figure 20) to the nitrogen piping system so that it could still be accessed if thefloodwater level rose higher. Before leaving the site, the supervisor also helped transfer moreorganic peroxide products into refrigerated trailers.

40

CSB · Investigation ReportFigure 20. Liquid Nitrogen Piping Extensions. A supervisor modified the liquid nitrogen piping,extending it to ensure that the connection point would be above the floodwater if the ride-out
crew needed to inject liquid nitrogen into one of the Low Temperature Warehouses that stillcontained organic peroxide products. These elevated (extended) connections, however, were nothigh enough; the rising floodwater eventually submerged them. (Source: CSB Photo)87.

As ride-out crew members cut power to Low Temperature Warehouses, the organic peroxide
products in those warehouses were moved either to other Low Temperature Warehouses that still
had power, or into refrigerated trailers that then were moved to the laydown area at the north end of
the facility (Figure 21). By Sunday night, the ride-out crew had manually cut the power to all of the
Low Temperature Warehouses except Low Temperature Warehouse 7. Additionally, the crew had
transferred the contents of those six Low Temperature Warehouses into six refrigerated trailers thatwere operating in the laydown area at the north end of the plant.

CSB · Investigation Report

41

Figure 21. Refrigerated Trailers in the Laydown Area. Six refrigerated trailers loaded with organic
peroxide products are shown at the Arkema Crosby facility. Two empty tanker trailers are also
shown at the top of the photo. (Source: Photo provided by Arkema)

88.

Throughout the chain of events during Hurricane Harvey, the ride-out crew management
continually communicated with the Arkema corporate crisis team so that it was aware of thesituation at the plant. The Arkema Crosby plant manager sent a daily e-mail to corporate personnel
detailing conditions at the plant and called them on his cell phone when key events occurred, suchas losing a Low Temperature Warehouse. The ride-out crew informed the Arkema corporate officeabout the site conditions and sought advice about the best means of dealing with the failure of the
Low Temperature Warehouse refrigeration systems.

89.

The heavy rainfall event continued to unfold throughout Sunday over much of southeastern Texas.
Hurricane Harvey had been moving slowly east-southeast during the past few hours, with heavy
rain bands continuing to form over the northwestern Gulf and tracking inland over much of theupper Texas coast and southwestern Louisiana. Rainfall in the range of 20 to 27 inches had fallen
across much of the Greater Houston area, and additional rainfall of 15 to 25 inches was projected
over the next several days. Rainfall totals in some locations were predicted to reach 50 inches,
historic for that area. As shown on Figure 22, this day had the largest daily rainfall (about 23
inches) near the Arkema Crosby facility from Hurricane Harvey [29].

42

CSB · Investigation ReportFigure 22. Hourly Rainfall on Sunday, August 27, 2017, During Hurricane Harvey. Cedar Bayougauge station 1740 measured hourly rainfall during Hurricane Harvey, as shown in this graph forAugust 27 [29].

3.5.
90.

MONDAY, AUGUST 28, 2017
Rain from Hurricane Harvey continued to fall in the area and floodwater at the facility continued torise throughout the day. At the Arkema Crosby facility, long periods of time passed with norainfall, but the surrounding area had accumulated so much water that the floodwater heights
continued to rise at the plant (Figure 23).

CSB · Investigation Report

43Figure 23. Hourly Rainfall on Monday, August 28, 2017 During Hurricane Harvey. Cedar Bayougauge station 1740 measured hourly rainfall during Hurricane Harvey, as shown in this graph forAugust 28 [29].

91.

aAround 2:00 am, the main CenterPoint a power transformers (Figure 24) failed due to the risingfloodwater. Two remaining generators (Figure 16, Generators 2 and 3) turned on at this point,
supplying power to Low Temperature Warehouse 7, the last remaining low-temperature organic
peroxide storage building (Figure 25). One of the generators then failed due to the floodwater, but
the other generator remained on, supplying power to Low Temperature Warehouse 7. Realizingthat the facility had no primary power supply and the generators might not last long, around 3:00
am, the ride-out crew went to move organic peroxide products out of Low Temperature Warehouse
7 and into two refrigerated trailers parked outside of the building. That remaining Low
Temperature Warehouse contained over 100,000 pounds of organic peroxide products and the rideout crew recognized the need to remove the products to the refrigerated trailers, where they stood abetter chance of staying cold.

CenterPoint is the company that provided electrical power to the Arkema Crosby facility.

44

CSB · Investigation ReportFigure 24. CenterPoint Transformers at the Arkema Crosby Facility. These are the main
CenterPoint power transformers onsite at the Arkema Crosby facility. (Source: CSB Photo)

Figure 25. Emergency Generator. This is one of the emergency generators that automaticallyturned on when the power failed at the Arkema Crosby facility. (Source: CSB Photo)

92.

Around 4:00 am, the wastewater treatment pumps failed because of a loss of power. Consequently,
the facility could no longer pump out the dikes surrounding the process equipment and thewastewater tanks. The wastewater treatment dikes began to fill with no way to drain them. While
this situation had no direct impact on the loss of refrigeration for the low-temperature organic
peroxide products, it increased the ride-out crew’s workload, further complicating their
responsibilities.
CSB · Investigation Report

45

93.

Around 5:00 am on Monday morning, as the floodwater continued to rise, the ride-out crew
proactively shut down the last generator (Figure 25) before the floodwater affected the electricalequipment, leaving no power to any of the Low Temperature Warehouses.

94.

On Monday morning, the ride-out crew checked the liquid nitrogen cooling system. The foot-longpiping extension that the plant supervisor had added the day before was now completely submergedby the floodwater, rendering the system inoperable. Based on the plant supervisor’s experience ofalmost 40 years at the Crosby facility, he believed that enough height was added to put the nitrogen
piping connection well above any anticipated floodwater level. Despite this effort, the floodwaterheight continued to rise, submerging the piping extension.

95.

During the morning, the equipment that the workers used to move the refrigerated trailers andpallets of organic peroxide products began to fail as the high floodwater affected electricalequipment in the forklifts and semi-tractor trucks. From this point forward, the ride-out crew could
not lift the pallets of organic peroxide products or move the refrigerated trailers to the laydown area
and the remaining three refrigerated trailers stood by the storage buildings (Figure 26). Moreover,
the water level around the Low Temperature Warehouses was about chest-high, making it evenmore difficult for ride-out crew members to move and take action. In addition, empty refrigerated
trailers, which workers had not yet filled with organic peroxide products and moved to the laydown
area, began to fail as their fuel tanks filled with water. As a result, only 9 of the 11 refrigerated
trailers stored organic peroxide products during the incident.

Figure 26. Three Refrigerated Trailers Not Moved to Higher Ground [33]. This aerial view shows
three refrigerated trailers (yellow and red circles) filled with organic peroxide containers near twoof the organic peroxide product warehouses after the Arkema ride-out crew evacuated the site.
(Photo Modified by CSB)46

CSB · Investigation Report

96.

On Monday morning, the Arkema corporate crisis team addressed possible scenarios for safely
managing the organic peroxide products that required low-temperature storage. The team’s toppriority was ensuring that the organic peroxide products did not combust. This priority necessarily
included confirming that the refrigerated trailers contained enough fuel to run the refrigeration
system, maintaining cooling, and accommodating potential options for moving the trailers offsite toanother Arkema facility or another organic peroxide company that could provide low-temperaturestorage. Although the corporate crisis team members did consider possible offsite storage, they
determined that neither drivers nor vehicles could get to the Crosby facility.

97.

If Arkema had wanted to move the organic peroxide products offsite, however, such a decisionneeded to have been made very early on, potentially even before Hurricane Harvey made landfall.
The Department of Transportation requires a driver who transports hazardous materials to have acommercial driver license (CDL) with a hazardous materials endorsement [34]. Because organic
peroxides are considered hazardous materials, Arkema would have had to find drivers that met thisrequirement. This requirement, in addition to obtaining additional drivers, especially before an
emergency situation like a hurricane, could have taken days or weeks to fully coordinate thelogistics.

98.

About 50 pallets of organic peroxide products remained in Low Temperature Warehouse 7 inFigure 16. The workers needed to move these pallets because the building had lost all power andrefrigeration capability. The ride-out crew members broke down the pallets in Low Temperature
Warehouse 7 and transferred the organic peroxide containers by hand to a refrigerated trailer parked
at a nearby building. All told, the ride-out crew moved about 2,160 organic peroxide containers byhand from Low Temperature Warehouse 7 to the last refrigerated trailer. This task finally ended
around midnight with ride-out crew members using flashlights to guide their way through thedarkened warehouse.

99.

By the end of Monday, workers had moved 11 different organic peroxide products―which required
low-temperature storage, were held in about 10,500 individual containers, and totaled more than
350,000 pounds―into 9 refrigerated trailers. Figure 27 and Figure 28 show the final location of thenine refrigerated trailers. The three refrigerated trailers near the south end of the facility, which
held more than 4,000 containers, were still sitting in floodwater, and the ride-out crew members
were concerned that these trailers would not be able to continue operating and refrigerating theorganic peroxide products they held.

CSB · Investigation Report47

Figure 27. Location of the Nine Refrigerated Trailers Containing Organic Peroxide Products.
(Source: Google Earth Image Modified by CSB)48

CSB · Investigation ReportFigure 28. Photo Identifying the Nine Refrigerated Trailers of Organic Peroxide Products. (Source:
Photos Provided by Arkema and Modified by CSB)

100. As shown in Figure 29, the floodwater eventually rose above the floor level of some of the Low
Temperature Warehouses. By that time, the ride-out crew members had emptied those Low
Temperature Warehouses of any organic peroxide products. If the organic peroxide products werestill housed there, regardless of the backup safety systems, the warm water would have quickly
heated the organic peroxide products, which likely would have combusted.

Figure 29. Low Temperature Warehouse at the Crosby facility. The red line shows the high-water
mark, just over five feet above the ground. (Source: CSB Photo)

CSB · Investigation Report49

101. By Monday evening, the most practical and safest way to move around the facility was by boat
(Figure 30). Two boats were onsite. The first was a smaller boat, which was onsite as part of the
Arkema site’s Hurricane Preparedness Plan. As the floodwater heights increased, a relative broughta ride-out crew member’s larger 16-foot boat to the site.

Figure 30. Boat Used by Ride-out Crew to Move Around the Arkema Crosby Facility. This photoshows two members of the ride-out crew in the 16-foot boat used to travel around the site during
the flood. (Source: Arkema Photo)102. After the ride-out crew communicated the dire nature of the situation to the Arkema corporate crisis
team, the crisis team alerted the Harris County emergency responders to the possibility of a releaseor a fire at the Crosby facility. The Arkema corporate crisis team also began to prepare for the
eventuality that when the refrigerated trailers not located in the laydown area lost power, theorganic peroxide products in those trailers would combust. The corporate crisis team performed ananalysis and found that if the refrigerated trailers failed, the products inside would likely reach its
Self-Accelerating Decomposition Temperature (SADT) and begin to combust within a few days.

3.6.

TUESDAY, AUGUST 29, 2017103. Around midnight, Harris Country emergency responders evacuated one member of the ride-out
crew after a concerned family member called local authorities. The remainder of the crew stayedbehind to check on the site and to assess the condition of the refrigerated trailers one more time inthe daylight before being evacuated.
104. On Tuesday morning, the ride-out crew saw that one of the refrigerated trailers had partially tippedover during the night and was leaning against the building (Figure 31). That tilting likely happened
either because the floodwater current was strong enough to knock out the supports, or the trailer
was overloaded with organic peroxide products, or a combination of both circumstances. When the50

CSB · Investigation Reportcorporate crisis team members received the picture in Figure 31 from the ride-out crew, theyreasoned that there likely was going to be at least one fire at the Crosby facility caused by thedecomposition of organic peroxide products. At least some of the refrigerated trailers―those not in
the laydown area―would not be able to maintain power and ultimately would lose cooling. The
Arkema corporate crisis team decided to request Harris County emergency responders to evacuate
the ride-out crew.

Figure 31. Condition of the Crosby Facility on the Morning of Tuesday, August 29, 2017. The rideout crew sent this photograph to the corporate crisis team showing the trailer on the left had
tilted. (Source: Arkema Photo Modified by CSB)

105. During the morning, the ride-out crew motored around the site by boat one last time to understandthe condition of the facility to provide an update to the Arkema corporate crisis team and theemergency responders. Around midday, Harris County emergency responders evacuated the rideout crew members by boat and transported them to a nearby fire station.
106. Figure 31 shows three of the trailers that the ride-out crew members could not move to the higher
ground in the laydown area. The cooling systems of all three refrigerated trailers shown in Figure
31 likely failed due to the high floodwater level. At that time, the six trailers at the laydown area
were still operating and cooling their organic peroxide products (Figure 32).

CSB · Investigation Report51

Figure 32. Refrigerated Organic Peroxide Trailers Located on High Ground. The refrigerated trailers
containing organic peroxide products and resting on high ground are pictured here, located on thenorth side of the Arkema Crosby facility during high floodwater conditions on Tuesday August 29,
2017. All six trailers at this location were incinerated during a controlled burn on September 3,
2017. (Source: Arkema Photo)107. During the day, the water level at the Crosby facility exceeded the top of the secondary containment
around the wastewater tanks, and organic liquids overflowed into the floodwater. Two waste watertanks located in the secondary containment were open to the atmosphere and the contents had
overfilled due to the excessive rainfall. Arkema reported the release of approximately 23,000
pounds of organic material into the floodwater (Table 2).

52

CSB · Investigation ReportTable 2. Chemicals Released into Floodwater. The listed chemicals (and quantities) were released
into Hurricane Harvey floodwater when the Arkema wastewater tanks overflowed.

ChemicalQuantity

Tert-amyl alcohol

2,026

Tert-butyl alcohol

2,026

Di-tert-butyl peroxide507

Di-tert-amyl peroxide

507

2,5-Dimethyl-2,5-di-(tert-butylperoxy)hexane

507

Ethylbenzene

405

Naphthalene

405

Naphtha (Heavy and Light)

6,089

Xylene405

1,2,4-Trimethylbenzene

2,229

Mineral Spirits

8,106(pounds)

108. During the afternoon, Arkema began to receive telemetry data from six of the nine refrigerated
trailers. The manufacturer of the six refrigerated trailers provided these data. The other three
trailers, supplied by a different manufacturer, did not have telemetry data capability. The telemetry
data recorded the air temperature within the refrigerated trailers and included information about
whether the refrigeration system was operating. Arkema provided these data to the emergency
responders and used the data in an attempt to estimate when the refrigerated trailers would begin to
combust. The estimated SADT for the refrigerated trailers was based on their organic peroxide
product contents and ranged from 19 to 70 °F. It should be noted that the telemetry data did notgive a temperature reading for the organic peroxide products in each trailer but rather thetemperature of the air inside the trailer. Moreover, the hectic nature of the loading process during
the storm prevented the ride-out crew members from definitively identifying the specific organic
peroxide products in each refrigerated trailer. Consequently, although the telemetry data offeredsome guidance regarding when a trailer stopped cooling and how warm the inside of the trailer was,this data could not be used to determine precisely when a refrigerated trailer and its contents would
combust.
109. When the ride-out crew evacuated the Crosby facility, the plant manager provided the emergency
responders with an overview of the facility and the status of the refrigerated trailers, to the best of
his understanding of the conditions at that time. The plant manager told the responders that a
number of the refrigerated trailers had lost power and could not maintain cooling. Arkema
maintained a person onsite at the emergency command center throughout the incident to relay
information to the emergency responders.

CSB · Investigation Report53110. Emergency responders handling the Arkema Crosby incident established a 1.5-mile evacuation
zone around the Arkema Crosby facility (Figure 33). Emergency response agencies―including
FEMA, the Environmental Protection Agency (EPA), and the Harris County Fire
Department―performed analysis and modeling that assumed the combustion of the refrigerated
trailers. The analysis evaluated a release from the sulfur dioxide storage tank, a release from theisobutylene storage tank, and ash fallout from the burning refrigerated trailers. Based on soot andparticulate matter resulting from the refrigerated trailer combustion, a one-mile evacuation zone
would be sufficient. To be conservative, provide greater safety for the surrounding residents, andefficiently allocate resources, emergency response officials extended the evacuation zone 1.5 miles.
As part of this decision process, the Arkema corporate crisis team was consulted, and the crisis
team agreed that 1.5 miles was sufficient given the likely scenario of organic peroxide products
combusting. As a result, emergency responders initiated evacuations of residents within theevacuation zone. About 205 residents were evacuated from their homes during this process.

Figure 33. Extended Evacuation Zone. The 1.5-mile extended evacuation area around the Arkema
Crosby facility is displayed within the red circle. (Source: Google Earth Image Modified by CSB)

111. At 4:50 pm, Arkema released a public statement alerting the public that the facility had been
evacuated and issued a warning about the situation. The statement addressed the incident asfollows:
At this time, refrigeration on some of our backup product storage
containers has been compromised due to extremely high water, rising tolevels that are unprecedented in the Crosby area. Arkema is limited in what
it can do to address the site conditions until the storm abates. We are54

CSB · Investigation Reportmonitoring the temperature of each refrigeration container remotely. At
this time, while we do not believe there is any imminent danger, thepotential for a chemical reaction leading to a fire and/or explosion within
the site confines is real [35].

3.7.

WEDNESDAY, AUGUST 30, 2017112. Emergency response personnel continued to evacuate residents and maintain the exclusion zone. A
number of Federal and local agencies supplied personnel to monitor roads entering the exclusionzone. The emergency responders had been warned that an explosion was “imminent” at theArkema Crosby facility. Some community members who were evacuated also believed that anincident at the plant could be imminent and therefore rushed to evacuate [36].
113. A Unified Command was set up to address the situation at the Crosby facility in accordance with
National Incident Management System (NIMS) practice. The Unified Command consisted ofHarris County Fire Marshal’s Office, Crosby Volunteer Fire Department, Harris County Sheriff’s
Office and Constables, Harris County Pollution Control, Arkema, EPA, Texas Commission on
Environmental Quality (TCEQ), and, later on in the incident, the City of Houston Bomb Squad.
The Crosby Volunteer Fire Department acted as Incident Command, and the command post was set
up at the Crosby Fire Station.
114. Figure 34 shows the location of emergency personnel around the evacuation perimeter. Roadblocks
were set up at strategic locations so that people could not enter the evacuation zone. Air monitoring
stations were established to test for combustion products on the perimeter of the evacuation zone.

CSB · Investigation Report55

Figure 34. Evacuation Perimeter and Key Staging Locations. The evacuation zone (red circle) issurrounded by emergency response personnel staging locations, including the roadblocks,
command center, and air monitoring stations. (Source: Google Earth Image Modified by CSB)

115. While it was becoming apparent to the Unified Command that an incident would occur at theArkema Crosby facility and emergency responders were planning for that inevitability, the massive
emergency response effort to Hurricane Harvey was also underway. As the hurricane advanced
from the Houston area into the Beaumont region, emergency responders needed to move as well.
Rainfall from the storm flooded portions of Interstate 10, leaving Highway 90, which cut throughthe middle of the evacuation zone for the Arkema Crosby incident, as the only viable route fortransporting resources (Figure 35). Due to this constraint and the importance of transporting
personnel and equipment to sites where they were needed, Highway 90 was open to such traffic
even while the remainder of the evacuation zone was being enforced. The Unified Command
staged emergency responders to block the road when the refrigerated trailers began to combust.
Due to flooding of surrounding roads, when Highway 90 closed it would take multiple hours to
detour traffic around the evacuation zone.

56

CSB · Investigation ReportFigure 35. Major Routes Between Houston and Beaumont. As shown on this Google Map, with
Interstate 10 flooded (shown with the red line), Highway 90 (shown with the green line) became an
important route for hurricane relief resources between Houston and Beaumont. The Arkema
Crosby location is shown by the blue circle. (Source: Google Maps Image Modified by CSB)

116. Arkema continued to provide telemetry data to the Unified Command to track the temperature in
the refrigerated trailers. Arkema and the emergency responders held regular meetings during the
day to discuss the site conditions and their next steps. Arkema provided a site map of therefrigerated trailers as well as an approximate list of the organic peroxide products loaded into eachtrailer and the SADT estimated for the products in each trailer. The Unified Command members
believed that they would be able to determine when the refrigerated trailers would combust basedon the temperature inside of the trailers. Three refrigerated trailers, however, could not provide
telemetry data and so neither Arkema nor the emergency responders knew the temperature in thesetrailers. In addition, Arkema was not certain about which products were in each trailer so the
SADTs were estimated.
117. Just before midnight, two of the police officers assigned to monitor the exclusion zone perimeter
were asked by a supervisor to respond to a high-water call. To respond, the officers left theirposition located at the northeast of the Arkema Crosby facility and were traveling west on Highway
90 when they entered a “large cloud of gas,” (Figure 36) which engulfed and entered their vehicle
as they neared the Arkema plant (Figure 37). The officers turned their vehicle around and retreatedback to their original location northeast of the Arkema Crosby facility. Because the cloud had achemical odor and the officers experienced adverse health symptoms (eye, skin, throat, andrespiratory irritation) from the exposure, a the officers concluded this cloud was a chemical releaseand they initiated a shutdown of Highway 90. The officers subsequently reported the release to the
Unified Command.

a

Only one of the two officers had a respirator, but the exposure occurred too quickly to provide time to use it. The officer had arespirator because of his participation in the Special Response Group. The Special Response Group is a small group of officers
trained to address activities such as protests. The group is equipped and prepared to handle any type of situation and to help
influence a peaceful resolution [237].

CSB · Investigation Report57

Figure 36. Police Vehicle Dash Cam Image of White Smoke. The left dash cam image shows theview of the white smoke cloud adjacent a to the Arkema Crosby facility at about 11:52 pm on
August 30, 2017. The image on the right provides a baseline of how the scene appeared on thedash cam outside of the white smoke. (Source: Harris County, Texas)

Figure 37. Approximate Wind Direction on August 30. The police officers who were first exposedto the white smoke cloud were travelling west on Highway 90 from the northeast roadblock area
on Highway 90. (Source: Google Earth Image Modified by CSB)

3.8.

THURSDAY, AUGUST 31, 2017118. Around midnight, amid reports of smoke at the Arkema facility, the Unified Command conducted asafety briefing with the emergency responders at the fire station, which was serving as the base ofa

The center of the white smoke crossed Highway 90 at approximately 29.947683N 95.018305W as measured by the police
vehicle dash cam.

58

CSB · Investigation Reportoperations. Units were briefed on the situation at the plant and were advised to remain upwind of
any potential release.
119. The available telemetry data did not show any spike in temperature within the refrigerated trailers,so the Unified Command dispatched two Crosby Volunteer Fire Department members to determine
whether a fire was in progress at the Crosby facility. The firefighters did not identify anything
resembling organic peroxide decomposition at the facility and reported back to the command post.
At 12:30 am, with no confirmation of fire or smoke at the Arkema facility, officials concluded theinitial white smoke was a “low lying weather cloud” and reopened Highway 90 to traffic. Neither
telemetry data nor air monitoring data indicated any signs of combustion and, as stated previously,
Highway 90 represented a vital corridor to move emergency responders toward the Beaumont area,
where help was needed. The command center also relied on the telemetry data and believed that
there would be some warning of any organic peroxide decomposition in the refrigerated trailers.
Unknown to the Unified Command at the time, however, the refrigerated trailer that likely
generated the vapor cloud did not have telemetry data capability.
120. The police officers, who first reported driving through the cloud, believed they had driven through achemical release and they informed other police officers that the cloud was recorded on theirvehicle’s dash cam, proving the release that they reported. Three other police officers then drove
their vehicles on Highway 90 to check on those officers and review their dash cam footage. As
they passed near the Arkema facility, the three officers also drove through a cloud originating at theArkema facility. Even though they turned off their air conditioning, the white smoke still made its
way into the vehicles.
121. When the three police officers arrived at the northeast boundary of the exclusion zone, they
reviewed the dash cam footage from the first police vehicle that showed the white smoke cloud.
The three police officers who had most recently driven through the cloud reported watery eyes andscratchy throats. The three police officers soon believed that they also had been exposed tochemicals from the release at the Arkema facility. From their location, the three police officers
could see a black cloud coming from the Arkema facility rising above Highway 90 (Figure 38).
That cloud and their symptoms combined with the flooding of all nearby roads and the officers’
desire to get prompt medical attention led the police officers to drive west down Highway 90
toward the command post and a hospital that was not flooded. In total, five police officers in four
police vehicles drove down Highway 90. The officers called to request medical assistance when
they reached the southern end of the exclusion zone.

CSB · Investigation Report59Figure 38. Police Vehicle Dash Cam Image of Black Smoke. The yellow circle shows the blacksmoke emanating from the Arkema Crosby facility at about 1:30 am on August 31, 2017. When thisimage was recorded, the police vehicle was parked on Highway 90 near Shady Lane, about 2.5
miles northeast of the Arkema Crosby facility. (Source: Harris County, Texas Modified by CSB)

122. As the police vehicles drove west on Highway 90, the officers were again exposed to a cloud
emanating from the Arkema facility. The health symptoms of the five officers began to worsen.
By the time they reached the southern end of the exclusion zone, they were experiencing nausea
and severe headaches. Other emergency responders decontaminated the police officers
complaining of exposure and flushed their exposed skin with water.
123. When the officers reached the forward command post they told the emergency responders there
what they had experienced and officials shut down Highway 90. From that point forward, Highway
90 remained closed to traffic until the all-clear was given on September 4.
124. Emergency medical technicians (EMTs) were called to assist with the police officers. While the
EMTs were on the way to the scene, they drove through a cloud as well. By the time these EMTs
arrived on scene, a number of police officers were experiencing symptoms of exposure, including
vomiting. Shortly after the EMTs arrived, three of the EMTs also reported possible exposure
symptoms. Ultimately, 21 emergency responders reported to the hospital for a medical evaluation
related to exposure to the smoke coming from the Arkema Crosby facility.
125. At around 2:00 am, the organic peroxide products in the refrigerated trailer that had tipped on
Tuesday morning decomposed to the point where they combusted and the refrigerated trailer caught
fire. Figure 39 shows the burned trailer the next morning. The two refrigerated trailers outside
Low Temperature Warehouse 7 are also visible in the figure. These two refrigerated trailers were
the next ones that the Unified Command anticipated would decompose and burn.

60

CSB · Investigation ReportFigure 39. First Refrigerated Trailer to Burn at the Arkema Crosby Facility. The first refrigerated
trailer to burn is shown smoldering outside of Building 21 [37].

126. During the afternoon, the EPA conducted flyovers of the Crosby facility to perform air monitoring.
The monitoring found low levels of peroxide immediately downwind of the refrigerated trailer that
had burned during the night. It should be noted that the flyover was conducted at a high altitude
and did not necessarily reflect conditions on the ground.
127. At 4:55 pm, Arkema released a statement to the public discussing the situation at the Crosby facility[38]. The statement read in part as follows:
Right now, we have an unprecedented 6 feet of water at the plant. We have lost
primary power and two sources of emergency backup power. As a result, we havelost critical refrigeration of the materials on site that could now explode and cause asubsequent intense fire. The high water and lack of power leave us with no way toprevent it [38].

3.9.

FRIDAY, SEPTEMBER 1, 2017

128. Arkema held a press conference to update the community, and Harris County Pollution Control
released the following statement:
To reduce risk of exposure, residents should stay indoors and close allwindows and doors along with shutting of air conditioning to close off the
air intake into the home. If going outside is unavoidable, try to move outof the line of the smoke plume and minimize time outdoors for work,
exercise or play [39].

CSB · Investigation Report61129. During the day, Harris County helicopters were used to survey the condition of the Arkema Crosby
facility. The helicopters flew over the refrigerated trailers to check for signs of combustion and tosurvey the isobutylene and sulfur dioxide feedstock tanks a that were the driving factor in the Crosby
facility’s Risk Management Plan worst-case scenario evaluation. At 10:00 am, the facility appeared
to be stable with no indication of combustion from the eight remaining refrigerated trailers loadedwith organic peroxide products.
130. Around 5:00 pm, two more refrigerated trailers ignited and burned. At that point, the threerefrigerated trailers that could not be moved to high ground because of the floodwater on Monday
had all burned, leaving the six refrigerated trailers with organic peroxide cargo in the laydown area
still uncombusted. Figure 40 shows the smoke plume from the two burning trailers and Figure 41 is
an image of the remains of the two refrigerated trailers after they combusted.

Figure 40. The Second and Third Refrigerated Trailers Burning. Fire and smoke are visible from two
refrigerated trailers burning at the Arkema Crosby facility on September 1, 2017 [40].

aSee additional information on these tanks in Section 11.1 and Section 11.2.

62

CSB · Investigation ReportFigure 41. Remains of the Second Fire that Consumed Two Trailers Storing Organic Peroxide
Products. The second fire consumed two refrigerated trailers storing organic peroxide products;
the remains of those trailers are shown in this image. (Source: CSB Photo)

3.10. SATURDAY, SEPTEMBER 2, 2017131. On Saturday, September 2, 2017, only six refrigerated organic peroxide trailers remained (Figure42). These six remaining refrigerated trailers were also more likely to have working refrigeration
units, so it was uncertain how long they would last until decomposition and combustion occurred.

CSB · Investigation Report63Figure 42. Photo Showing the Location of the Last Six Refrigerated Organic Peroxide Trailers [41].
(Photo Modified by CSB)

132. Around 1:20 pm, the Unified Command conducted another aerial reconnaissance flight over thefacility. This flyover indicated that at least one of the refrigerated trailers had lost cooling capacity.
This aerial flight identified some decomposed material near the remaining trailers and smoke, but
no fire. Based on infrared camera images, the material leaking out of at least one of the refrigerated
trailers was at an elevated temperature. Arkema representatives were consulted to identify thesubstance. Although these representatives were unsure about the composition of the material, theysuspected that the leaking material was a byproduct of decomposing organic peroxides.
133. As the evacuation continued, residents, who were not allowed to enter the perimeter, began toexpress concern over their inability to check on their homes and gather their belongings. These
residents began to pressure officials to end the evacuation and remedy the situation at the Crosby
facility. To facilitate an end to the evacuation, the Unified Command met around 6:00 pm with a
Regional Response Team to discuss the possibility of executing a controlled burn of the remaining
six refrigerated trailers. The group developed a plan to perform a controlled burn and presented it
to Arkema for final approval. By 7:00 pm, all parties within the Unified Command, including
Arkema, had approved the plan.
134. One concern was the isobutylene storage tank, located about 40 yards from the closest refrigerated
trailer in the laydown area (Figure 43). This concern focused on the risk that the controlled burn of
the six refrigerated trailers would heat the isobutylene tank, potentially causing a release or even an
explosion. Emergency responders believed that the distance was great enough and that the venting
on the isobutylene tank was sufficient to avoid a serious incident, but they planned the controlledburn so that the last refrigerated trailer to be burned would act as a heat shield for the isobutylene
storage tank while the other five trailers combusted; the last trailer then would be burned by itself.

64

CSB · Investigation ReportFigure 43. Isobutylene Storage Tank at the Arkema Crosby Facility. The isobutylene tank posed aconcern because the controlled burn of the six refrigerated trailers in the laydown area would
occur within about 40 yards of this storage tank. (Source: CSB Photo)

3.11. SUNDAY, SEPTEMBER 3, 2017135. The Unified Command conducted another aerial reconnaissance flight over the facility on Sunday
and identified additional material leaking out of the refrigerated trailers, indicating that some typeof reaction was still ongoing within the refrigerated trailers. In light of this information, emergency
responders decided that it was unsafe to approach the refrigerated trailers or to try handling any ofthe products within the trailers.
136. The Unified Command reconvened around 10:00 am to discuss next steps. The emergency
responders were concerned about the intermittent decomposition occurring in the refrigerated
trailers and the lack of information about the next likely event. The responders also were concerned
about not having a timeline for combusting all of the organic peroxide products. Evacuatedresidents were still anxious to return to their homes. Under the circumstances, a controlled burnmade sense to end the incident quickly and precisely. The team decided to move forward with thecontrolled burn plan developed the night before.
137. Arkema provided information on the sulfur dioxide and isobutylene storage vessels to the Unified
Command to help evaluate the hazards posed by the location of the tanks and the risk of a release.
Using this information, the Unified Command determined that neither the sulfur dioxide nor theisobutylene tank was likely to release product during the controlled burn.
138. At 12:45 pm, the entry teams were briefed about the controlled burn plan. Before the controlledburn, a team would first conduct visual reconnaissance of the isobutylene tank to ensure that no

CSB · Investigation Report65decomposed organic peroxides had leaked near the isobutylene tank because such leaked materials
could catch fire and result in flame impingement on the isobutylene tank. If the team foundevidence of leaked material near the isobutylene tank, it would reevaluate its plan and identify away to drain the tank before performing the controlled burn. If the team did not find evidence of
leaked material, the controlled burn operation would begin.
139. The visual reconnaissance team determined that it was safe to commence the controlled burn. For
the controlled burn, Harris County emergency response personnel placed an incendiary device oneach of the six refrigerated trailers in the laydown area that could be activated remotely. The entry
members all wore a self-contained breathing apparatus because of the potential health risk posed byunknown decomposition products leaking from the refrigerated trailers.
140. Around 3:40 pm, the emergency responders commenced the controlled burn of the remaining six
trailers containing organic peroxide products. The Harris County Fire Marshal’s Office released apublic statement warning the public about the impending controlled burn [42].
141. Around 9:00 pm, additional air monitoring was conducted within the evacuation zone and there
were no readings above the baseline level. The emergency response team determined that no healththreat to the community remained and that the evacuation zone could be lifted once security
personnel for the Arkema Crosby facility were in place.

3.12. MONDAY, SEPTEMBER 4, 2017142. Around 1:00 am, the Unified Command authorized lifting of the evacuation zone and allowed
residents to return to their homes.

66

CSB · Investigation Report

4. FLOOD INFORMATION
143. The Arkema Crosby facility is located in Harris County, Texas. According to the Harris County
Flood Control District, a flooding is the primary natural disaster concern due to factors such as flat
terrain, poor water-absorbing clay soils, and annual average rainfall of 48 inches [43].
144. The National Oceanic and Atmospheric Administration (NOAA) identifies inland flooding as“often the most deadly” effect from hurricanes, stating, “While storm surge is always a potential
threat, more people have died from inland flooding in the last 30 years [44].” NOAA notes thatsome of the highest rainfall totals have occurred when weaker storms either drifted slowly or stalledover an area [44]. Hurricanes can pose a major threat to communities hundreds of miles from thecoast because intense rainfall can accompany these tropical storms [44]. NOAA recommends thatwhen residents and businesses in coastal flood hazard areas hear “hurricane,” they should thinkinland “flooding” [44].
145. Hurricane Harvey was the strongest hurricane to strike Texas since 1961 and the first Category 4
hurricane to make landfall in the United States since 2004 [45]. The Harris County Flood Control
District reported that about one trillion gallons of water fell on Harris County as a result of
Hurricane Harvey rainfall over four days [46]. The rain from Harvey could cover the county’s
1,800 square miles with 33 inches of water [46]. The storm flooded more than 136,000 structures[46].
146. The Harris County Flood Control District operates a flood warning system that uses 154 gauge
stations with sensors that transmit data on rainfall and stream level [47]. (Figure 44). The gaugesystem was initiated in 1983 with 13 gauges and expanded to its current 154 gauges [47].

aThe Texas legislature created the Harris County Flood Control District in 1937 following devastating floods in 1929 and 1935
[127]. The mission of the flood control district is to “Provide flood damage reduction projects that work, with appropriate
regard for community and natural values [127].”

CSB · Investigation Report67Figure 44. Harris County Flood Control District Gauge Map. This Harris County gauge map shows
the 7-day rainfall totals (in inches of water) attributable to Hurricane Harvey [48]. The approximate
location of the Arkema Crosby facility is shown by the red circle. (Image Modified by CSB)

147. Harris County has 22 watersheds a that drain into Galveston Bay [49]. b The Arkema Crosby facility
is located in the Cedar Bayou watershed (Figure 45). About 37,000 people live within the Cedar
Bayou watershed, which covers an area of 202 square miles and includes 128 miles of open streams[50]. The main stream of Cedar Bayou is about 40 miles long, flows south, and discharges into
Galveston Bay [50].

a“A watershed is a geographical region that drains to a common bayou, creek or other waterway. There are 22 major watersheds
in Harris County [139].”b
See the section on Harris County Watersheds in the Flood Insurance Study: Harris County, Texas and Incorporated Areas:
Volume 1 of 12 from January 6, 2017 [49, p. 21]. To access Volume 1 of the Flood Insurance Study (number 48201CV001E),
access the FEMA Flood Map Service Center website, enter the address for the Arkema Crosby facility (18000 Crosby Eastgate
Rd., 77532), and then click “Show all products for this area.” Click the “Effective Products” folder, and then click “FIS
Reports.” Scroll down the page to map 48201CV001E under the “Product ID” column.

68

CSB · Investigation ReportFigure 45. Map of the Cedar Bayou Watershed in Harris County, Texas. The white and blue shaded
area on the right is the Cedar Bayou watershed. The red star shows the approximate location of
the Arkema Crosby facility [50]. (Image Modified by CSB)

148. Congress established the National Flood Insurance Program in 1968 [51, p. 1] and the Federal
Insurance Administration began to assume responsibility for flood insurance studies during the late1970s [52, p. 1]. a The Federal Emergency Management Agency (FEMA) now administers thisprogram [51, p. 2]. Among its advances, the Flood Insurance Studies (FIS) group began providing
maps and reports to establish a basis for flood insurance and for the regulation of floodplain
development [52, p. 2]. These maps include the Flood Insurance Rate Map (FIRM) [52, p. 3].
FIRMs are used for tasks such as the following:•

Determining whether a property is in a floodplain;•

Showing the flood insurance zone of the property; and•Establishing the approximate base flood elevation for the property [52, p. 13]. b, caStarting in 1954, the Tennessee Valley Authority (TVA) was the first Federal agency to prepare regional flood hazard
information for communities [52, p. 1].
b
After 1989, Flood Insurance Rate Maps began to include additional information, such as how a floodplain is divided intofloodway and flood fringe, where streams are studied in detail. See Utilizing Information from Flood Hazard Studies at pages
6-15 and 6-16 [52].
c
The Base Flood Elevation is the elevation of flooding having a one percent chance of being equaled or exceeded in any given
year. The Base Flood Elevation (BFE) is also known as the “base flood” and the “100-year flood” [61, p. 1].

CSB · Investigation Report69149. The Cedar Bayou watershed has a known history of flooding [50]. Figure 46 shows that theArkema Crosby facility is located within a floodplain. a Cedar Bayou and an unnamed tributary
stream are located north and east of the Crosby facility, while the Adlong Ditch sits to the west.
From the Arkema facility, the Adlong Ditch flows southeast about three miles and connects into
Cedar Bayou. Flooding at the Arkema Crosby facility is a function of, among other factors, rainfall
within the area and the capability of the Adlong Ditch and Cedar Bayou to carry such rainfall into
Galveston Bay. b

aA floodplain is the area adjacent to rivers or streams that is naturally subject to flooding [128]. “From time to time, bayous andcreeks naturally come out of their banks due to heavy rainfall and inundate the adjacent land. This area that is inundated isreferred to as a floodplain [139].” (Hyperlink added.) “The mapped floodplain is only an estimate of where flooding ispredicted to occur from a bayou or creek, given a set of parameters including a hypothetical rainfall occurring over a watershed
for an assumed amount of time. During an actual rain event, natural conditions can result in greater amounts of rainfall or
runoff, resulting in flood levels deeper and wider than shown on the FEMA Flood Insurance Rate Maps [127].” (Hyperlink
added.)b
USGS provides additional flood information including how the 100-year flood is determined, and the accuracy of the one
percent annual exceedance probability (AEP) flood (also known as the 100-year flood) [216].

70

CSB · Investigation ReportFigure 46. Approximate Floodplain Map of the Area Near the Arkema Crosby Facility. The Arkema
Crosby facility (red star) is located between the Adlong Ditch and the unnamed tributary to Cedar
Bayou floodways a and is within both the 100-year b and 500-year c floodplain [53]. (Image Modified
by CSB)

150. The Harris County Flood Control District gauge station 1740 (Figure 47) is located about three
miles northeast of the Arkema Crosby facility (Figure 48), where Cedar Bayou goes under Highway
90.

aFloodway is the area that must be kept free of encroachments for a 100-year flood [128]. Encroachment refers to floodplain
development that could obstruct flood flows [129].
b“A 1 percent (100-year) floodplain, also known as a Special Flood Hazard Area on a Federal Emergency Management Agency(FEMA) Flood Insurance Rate Map (FIRM or floodplain map), is an area at risk for flooding from a bayou, creek or otherwaterway overflowing during a 1 percent (100-year) flood. Structures located in a 1 percent (100-year) floodplain have aminimum of a 1 percent chance of flooding in any given year. Statistically, structures located in a 1 percent (100-year)
floodplain have a minimum of a 26 percent chance of flooding during a 30-year period of time, which is the duration of manyhome mortgages. And, the risk for flooding increases the closer a structure is to a bayou or a creek, assuming the structure is
not elevated. A mapped 1 percent (100-year) floodplain is an area where land development is regulated by a city or a county[139].” (Hyperlink added.)c“A 0.2 percent (500-year) floodplain is an area at risk for flooding from a bayou, creek or other waterway overflowing during a
0.2 percent (500-year) flood. Structures located in a 0.2 percent (500-year) floodplain have a minimum of a 0.2 percent chanceof flooding in any given year. Statistically, structures located in a 0.2 percent (500-year) floodplain have a minimum of a 6
percent chance of flooding during a 30-year period of time, which is the duration of many home mortgages. And, the risk forflooding increases the closer a structure is to a bayou or a creek, assuming the structure is not elevated [139].” (Hyperlink
added.)

CSB · Investigation Report71Figure 47. Gauge Station 1740. This gauge station uses a bubbler system to measure the Cedar
Bayou water elevation at Highway 90, about three miles northeast of the Arkema Crosby facility. a(Source: CSB Photo)a“A bubbler is one of three types of real-time, water-level measuring devices used at gage stations throughout Harris County. A
bubbler system is submerged under water and uses a tube with an opening, called an orifice line, which runs from a transmitterat a gage station to the opening of the tube on the submerged part of the device to measure pressure and determine water levels.
A fixed flow of air is passed through the tube, and the internal pressure of the air in the tube and the external pressure of thewater outside the tube provide a water-level reading [139].” (Hyperlink added.)72

CSB · Investigation ReportFigure 48. Arkema Crosby Facility and the Cedar Bayou Gauge Station 1740. This map shows theproximity of the Arkema Crosby facility (red star) to the nearest Cedar Bayou gauge station (redcircle). Gauge station 1740 is about three miles northeast of the Crosby facility [48]. (Image
Modified by CSB)

151. During Hurricane Harvey, gauge station 1740 recorded 38 inches of rain (Figure 49) raising thewater level in Cedar Bayou to nearly 59 feet (Figure 50), the highest water level measured at thislocation since the gauge station was installed in 1984 [29]. a This amount of rain is the equivalent of
80 percent of the average annual rainfall for the Houston area, delivered over the course of just a
few days [54]. On August 27, 2017, this gauge recorded about 21.5 inches of rainfall, exceeding
both the 12-hour and 24-hour 500-year rainfall criteria for Harris County by more than two inches. bab

Click on “Stream Elevation” tab for Gauge station 1740 to view historical storm elevation data [29].
For Harris County, a 0.2 percent (500-year) rainfall is about 19 inches in 24 hours. A 1 percent (100-year) rainfall is just over
13 inches in 24 hours or just under 11 inches in 12 hours [217]. For the Arkema Crosby facility, which is in the Cedar Bayouregion of Harris County, a 0.2 percent (500-year) is 19.3 inches in 24 hours, 20.7 inches in two days, and 22.3 inches in fourdays [49, p. 33]. As shown in Figure 49, Hurricane Harvey rainfall exceeded all of these benchmarks for a 500-year rainfall
event.

CSB · Investigation Report73Figure 49. Rainfall Totals During Hurricane Harvey. Cedar Bayou gauge station 1740 measured
rainfall totals during Hurricane Harvey [29]. The maximum 12-hour rainfall of nearly 14 inches
occurred during the morning of August 27, 2017 [29].

Figure 50. Gauge Station 1740 Stream Elevation Data. The graphs show Cedar Bayou stream
elevation during Hurricane Harvey [29]. About 59 feet was the largest stream elevation recorded
at about 1:33 am on August 28, 2017 [29]. a

152. The 59-foot Cedar Bayou water level exceeded the nearly 57-foot predicted elevation for 0.2percent flood frequency (Table 3) [29].b As a result, the flooding at the Arkema Crosby facility
following Hurricane Harvey was greater than that of a 500-year flooding event. Given thea

For Cedar Bayou at Highway 90 (gauge station 1740), top of bank (TOB) is 53.4 feet, and bottom of channel (BOC) is 36.09
feet [29]. Click the “Stream Elevation” tab for Gauge station 1740 [29].
bClick the “Stream Elevation” tab for Gauge station 1740 to view historical stream elevation data [29].

74

CSB · Investigation Reportfloodplain where the Crosby facility is located, there is about a 10-percent chance for this level offlooding in any 50-year period [55].
Table 3. Predicted Flood Frequency Elevations. These flood frequency elevations are projected for
Cedar Bayou at gauge station 1740 [29].

153. The Harris County Flood Control District maintains historical records for each gauge station.
Before Hurricane Harvey, the previous high-water mark for Cedar Bayou at gauge station 1740 was
set in 1994 with a water elevation of about 56 feet (Table 4) [29].
Table 4. Historical Storm Elevation Data. These historical storm elevations are provided for Cedar
Bayou at gauge station 1740 [29]. Although not identified by the Harris County Flood Control
District on its website, the 1994 event was likely Hurricane Rosa.

4.1.

HISTORY OF FLOOD INSURANCE RATE MAP FOR THE ARKEMA CROSBYFACILITY154. The current and two previous versions of the Flood Insurance Rate Map for the Arkema Crosby
facility are accessible on the FEMA Flood Map Service Center website. These maps show that the
Crosby facility has become more susceptible to flooding over time. Available versions of theseflood maps include the following:

CSB · Investigation Report75•

September 1985 – the Flood Insurance Rate Map showed that the vast majority of the
Crosby facility was located in an area designated as “Zone C – Area of Minimal Flooding”[56]. a•November 1996 – the Flood Insurance Rate Map located the vast majority of the Crosby
facility in “Other Areas – Zone X – Areas determined to be outside the 500-year floodplain”[57]. b A small portion of the southwest corner of the facility was located in Zone A – thespecial flood hazard areas inundated by 100-year flood, with no base flood elevations
determined [57].

•June 2007 – The current Flood Insurance Rate Map shows that the entire Crosby facility iseither in the 100-year or 500-year floodplain [58]. c

155. Of these map revisions, the June 2007 update is significant because it established that the entire
Arkema Crosby facility is located within a floodplain (Figure 51). Some portions of the facility arein the 100-year floodplain and the remainder of the site is in the 500-year floodplain.

a

To access the September 27, 1985, Flood Insurance Map (number 4802870240D), access the FEMA Flood Map Service Center
website, enter the address for the Arkema Crosby facility (18000 Crosby Eastgate Rd., 77532), and then click “Show all
products for this area.” Click the “Historic Products” folder, and then click “FIRM Panels.” Scroll down the page to map
4802870240D under the “Product ID” column.
b
To access the November 6, 1996, Flood Insurance Map (number 48201C0535J), access the FEMA Flood Map Service Center
website, enter the address for the Arkema Crosby facility (18000 Crosby Eastgate Rd., 77532), and then click “Show all
products for this area.” Click on the “Historic Products” folder, and then click on “FIRM Panels.” Navigate to page three tolocate map 48201C0535J under the “Product ID” column.
c
To access the June 18, 2007, Flood Insurance Map (number 48201C0535L), access the FEMA Flood Map Service Center
website, enter the address for the Arkema Crosby facility (18000 Crosby Eastgate Rd., 77532), and then click to either view or
download using one of the two “Map Image” icons.

76

CSB · Investigation ReportFigure 51. Excerpt from the June 2007 Flood Insurance Rate Map (FIRM). This part of the FIRM
shows that the Arkema Crosby facility is located in the 100-year and 500-year floodplains [58].
(Image Modified by CSB)

156. The FEMA flood map website also offers access to digital flood map images. Figure 52 shows adigital flood map of the Arkema Crosby facility. This map places the Arkema electric utility supply
and organic peroxide product Low Temperature Warehouses in the 100-year floodplain.

CSB · Investigation Report77Figure 52. Southern Part of the Arkema Crosby Facility in the 100-Year Floodplain. This digital
image shows that the southern part of the facility, where Arkema’s electric utility equipment andrefrigerated organic peroxide product storage facilities are located, sits in the 100-year floodplain.
The blue portion of the map is Zone AE – the 100-year floodplain [58]. a

157. In addition, a September 2016 report from Factory Mutual Insurance Company (FM Global),
Arkema’s insurer, shows that the Adlong Ditch represents a flood hazard to the Arkema Crosby
facility. The FM Global report also confirms that some portions of the facility are in the 100-year
floodplain while the remaining portions are in the 500-year floodplain.

4.2.

FLOOD INSURANCE STUDY158. In addition to supplying Flood Insurance Rate Maps, FEMA also provides communities with Flood
Insurance Study reports that include detailed flood elevation maps called flood profiles (Figure 53)[59]. The Flood Insurance Study for Harris County, Texas includes detailed flood elevation maps
for the streams near the Arkema Crosby facility including Cedar Bayou, Adlong Ditch, and theunnamed tributary northeast of the plant [59]. baTo access the digital version of the June 18, 2007 Flood Insurance Map (number 48201C0535L), access to the FEMA Flood
Map Service Center website, enter the address for the Arkema Crosby facility (18000 Crosby Eastgate Rd., 77532), and thenclick the icon for “View Web Map” [58].
bAlthough the Flood Insurance Study for Harris County has 12 volumes, Volume 1 and Volume 8 are the most relevant tounderstanding flood risks at the Arkema Crosby facility. On the FEMA Flood Map Service Center website, Volume 1 is
product identification number 48201CV001E and Volume 8 is 48201CV008D [49], [60]. To access these documents navigate
to the FEMA Flood Map Service Center website, enter the address for the Arkema Crosby facility (18000 Crosby Eastgate Rd.,
77532), then click “Show all products for this area,” then click the folder for “Effective Products,” and finally click the “FIS
Reports” [59].

78

CSB · Investigation ReportFigure 53. Excerpt from the Adlong Ditch Flood Profile. This excerpt from the Adlong Ditch flood
profile shows the estimated water elevation for various flood chance scenarios adjacent to the
Arkema Crosby facility [60, p. 35]. The red rectangle was placed by the CSB to show that theapproximate floodwater height from Hurricane Harvey was more than two feet above the 500-year
flood elevation. Exceeding the 500-year flood elevation by more than two feet is significant
because the flood elevation difference between the 100-year and 500-year events is less than one
foot. (Graphic Modified by CSB)

4.3.

BASE FLOOD ELEVATION

159. As shown in Figure 54, the Flood Insurance Rate Map indicates that for the Arkema Crosby
facility, the base flood elevation, which is equivalent to the 100-year flood level, is 52 feet [58].

CSB · Investigation Report79Figure 54. Base Flood Elevation for the Arkema Crosby Facility. The Flood Insurance Rate Map
shows that the base flood elevation for the Crosby facility is 52 feet [58]. (Map Modified by CSB)

160. Figure 55 shows one of several elevation survey markers at the Arkema Crosby facility. The baseflood elevation is six inches above the elevation of this survey marker.

80

CSB · Investigation ReportFigure 55. Elevation Survey Marker Near the Liquid Nitrogen Storage Tank. The metal plate on topof the concrete block shows that the elevation is 51.5 feet, about six inches lower than the baseflood elevation. During Hurricane Harvey, floodwater exceeded the height of the survey marker bymore than three feet. (Source: CSB Photo)161. According to FEMA, floods often exceed the base flood elevation. FEMA cautions that during
recent storms―including Katrina, Ike, and Sandy―floodwater level exceeded the base flood
elevation by several feet in some areas, and flooding extended far beyond the flood area shown on
the Flood Insurance Rate Maps [61].

4.4.

2016 INSURANCE REPORT IDENTIFIED AND EVALUATED FLOOD RISK

162. FM Global is a Rhode Island-based insurance company with offices worldwide that provides loss
prevention insurance to large corporations. When FM Global a engineers visit a location for a clientcompany, they perform a number of evaluations, including assessing whether any natural hazard
loss exposures exist by reviewing flood, wind, and earthquake maps [62, p. 21].
163. A year before Hurricane Harvey, FM Global engineers visited the Arkema Crosby facility, met with
the Crosby plant manager, and produced a report that identified the Crosby facility as susceptible toflooding hazards, among other insurance risks. b The September 2016 FM Global report specificallya

FM Global was the insurance provider for the Arkema Crosby facility before 2017, but Arkema switched insurance companies
in 2017, so FM Global was not the insurance carrier at the time of Hurricane Harvey.
b
The plant manager who met with FM Global representatives in September 2016 retired from Arkema in early 2017. The
Arkema manager who then assumed an interim role was not aware of the FM Global report.

CSB · Investigation Report81

showed that the Adlong Ditch presented a flooding hazard to the Arkema Crosby facility. The
report also found that the site was in both the 100-year and 500-year floodplains. FM Global
developed property damage and business interruption loss estimates for the 100-year and 500-year
flooding, which indicated that a 500-year flood could cause five times more property damage and16 times more extensive business interruption losses than a 100-year flood event.
164. FM Global states that its engineers gather 700 data points during more than 100,000 site visits eachyear [63]. FM Global analyzes these data and uses them to predict the locations where insurance
losses are likely to occur and the exposures most likely to result in a loss [63]. FM Global provides
its clients with reports to help prioritize their risk improvement efforts [63]. Among several FM
Global risk tools, the company’s benchmarking tool, RiskMark, measures the risk quality ofevaluated sites [63]. RiskMark uses a 100-point scale, with higher scores representing wellmanaged and higher quality risks with lower risk of loss [64]. RiskMark includes four components,
including natural hazards, such as flooding [62, p. 21]. FM Global reports that locations with thelowest RiskMark scores are seven times more likely to experience loss than those with higher
RiskMark scores [63]. In addition, FM Global reports that sites with low RiskMark scores havelosses 30 times more severe than sites with higher RiskMark scores.
165. The 2016 FM Global report also provided Arkema management with a RiskMark score. The score
for the Crosby facility fell in the bottom quartile compared with other Arkema facilities and other
FM Global client sites that manufacture hazardous chemicals. The Crosby facility received lowscores for natural hazards such as flooding. Although FM Global identified the flooding risk at theArkema Crosby facility, the FM Global report did not make any recommendations to Arkema toaddress its flood hazards. Furthermore, FM Global was satisfied with the changes that Arkema
made based on their report. It should be noted that the FM Global report pointed out multiple
issues at the Crosby facility and the facility addressed many of the issues.

82

CSB · Investigation Report5. FLOOD DESIGN AT THE ARKEMA CROSBY FACILITY
166. Although the CSB investigation found no single flood design basis for the Arkema Crosby facility,
the site’s hurricane plan, emergency plan, process hazard analysis (PHA), worst-case scenarios, andwritten statements issued by Arkema in relation to the Hurricane Harvey flooding all show how thefacility viewed its susceptibility to flooding. This viewpoint is expressed by Arkema’s postincident statements, which are consistent with those made by Arkema employees to CSB
investigators―the site had a history of flooding, and about two feet of water is the most employees
recall onsite before the Hurricane Harvey flooding.

5.1.

HURRICANE PREPAREDNESS PLAN

167. Among other storm preparations, the Arkema Crosby Hurricane Preparedness Plan includes thefollowing items to address flooding:

5.2.

•

Fill storage tanks, where practical to prevent them from floating;•Fill dumpsters with water to prevent them from floating;•Acquire an off-road forklift, with large tractor-style tires that is capable of moving through acouple of feet of floodwater [65];•Obtain a flat-bottom boat, capable of operating in shallow water [66]; and•Stock waders as part of the personal protective raingear.

EMERGENCY RESPONSE PLAN

168. The Arkema Crosby’s Emergency Response Plan discusses many potential emergency situations
including:•

Organic peroxide decomposition;•

Loss of electrical power; and•Severe weather events such as flooding.

169. The flooding and high-water section of the Emergency Response Plan does not consider the amountof flooding as seen during Hurricane Harvey. Arkema wrote its emergency plan with an unstatedemphasis on a lower level of floodwater. The Emergency Response Plan says:
Care shall be taken to be sure water is kept out of equipment, shops, control
rooms, offices, etc. These areas are to be checked during severe rainstorms
to prevent damage or personal injuries. Non-essential personnel are to bereleased when appropriate.
CSB · Investigation Report

83The following items must be checked during heavy rains:•

Monitor levels in all secondary tank containments.

•

Open storm water containment gates as needed.

•

Secure all containers and equipment as necessary.

•

Monitor levels in sanitary sumps.

170. The Emergency Response Plan describes preparatory actions and emphasizes worker safety during
severe weather. Arkema’s Emergency Response Plan, however, does not identify the possibility
that flooding could lead to a loss of electric power, the subsequent loss of refrigeration capability,
and the resulting decomposition of organic peroxide products.

5.3.

STORAGE BUILDING SAFETY GUIDELINES

171. The Arkema Crosby facility had a written policy which was intended to provide guidance, limits,and process safety information for organic peroxide storage at the facility. Among other items, thispolicy detailed the actions operators should take to provide cooling for the organic peroxide
products in the event that power is lost to the Low Temperature Warehouses. The policy was
updated in 2016 to direct workers to move organic peroxide products to refrigerated trailers if the
backup generators failed to operate upon loss of power to the Low Temperature Warehouses. The
liquid nitrogen system was to be used in the event that there was “no other alternative available.”At the 500-year flood level, if the refrigerated trailers had been loaded and placed in the laydown
area, as attempted during Harvey, the organic peroxide contents would have likely maintained
sufficient cooling to prevent a decomposition incident. a

5.4.

PROCESS HAZARD ANALYSIS

172. The Arkema team that performed the Low Temperature Warehouse PHA for the Crosby facility did
not document any flooding risk. b Had the Arkema PHA assessed flooding, the limited industry
guidance on flooding would likely have been insufficient to provide specific or sufficiently
conservative level of action to protect against the hazards posed by the flooding during Hurricane
Harvey. Even without this assessment, however, the Crosby facility appears to have had sufficientaDuring Hurricane Harvey, the flood water at Adlong Ditch reached about 54.5 feet. The elevation at the laydown area is 52 feetand the fuel tank for the refrigerated trailer is 3 feet 5 inches above the ground. If all refrigerated trailers had been placed in the
laydown area, they would likely not have lost refrigeration if workers could have stayed onsite to monitor them.
b
The Arkema Low Temperature Warehouse PHA was completed in November 2013. Arkema uses as low as reasonably
practicable (ALARP) in its risk assessment and risk mitigation programs. CCPS defines ALARP as follows: “The concept thatefforts to reduce risk should be continued until the incremental sacrifice (in terms of cost, time, effort, or other expenditure ofresources) is grossly disproportionate to the incremental risk reduction achieved. The term as low as reasonably achievable(ALARA) is often used synonymously [178].”84

CSB · Investigation Reportsafeguards in place to prevent loss of refrigeration in the Low Temperature Warehouses for a 100year flooding event.
173. Although Arkema’s corporate PHA policies in place at the time of the Low Temperature
Warehouse PHA included flooding as one of the possible initiating events, the Arkema Crosby
PHAs did not document any risk from flooding. The Arkema PHA covering the Low Temperature
Warehouses, however, identified the following three scenarios that could cause elevatedtemperature in the Low Temperature Warehouses, including:•

Loss of refrigeration because of a compressor failure;•

Loss of refrigeration because of a refrigerant leak; and•Loss of power.

174. To address possible loss of power, the Crosby PHA team identified safeguards, including thefollowing:•

Emergency generators that provide electricity to all low-temperature storage buildings;•

Liquid nitrogen supply for alternative cooling; and•Manual temperature checks conducted every two hours and the capability to relocate organic
peroxide products from an affected cold storage building to another building or to a portablerefrigerated trailer that is still capable of providing the required cooling.

175. The adequacy of flood risk safeguards was not assessed for Hurricane Harvey-like flooding in the
PHA process. Both Arkema’s own corporate policies and industry standards call for safeguards to
be independent of hazard initiating events. The flooding that caused the Crosby facility to loseelectrical power during Harvey, however, also provided a common failure mode for the safeguards
Arkema considered as protection layers, including:•

Emergency generators flooded and were not available;•

Liquid nitrogen piping flooded and was not available; and•Refrigerated trailers’ diesel fuel tanks flooded and were not available.

176. Lacking sufficient independent protection layers for the level of flooding it confronted during
Hurricane Harvey, the Crosby site was not protected and the organic peroxide products
decomposed. Appendix C provides additional analysis of the Arkema Crosby PHA.

CSB · Investigation Report

85

5.5.

PROCESS SAFETY WORST-CASE SCENARIOS

177. Each Arkema site develops a list of worst-case process safety scenarios to improve employee
awareness of the most significant hazards. Arkema communicates these hazards to employees insafety orientation training, and in periodic safety meetings.
178. Arkema managers developed the list of worst-case process safety scenarios by evaluating each of
the site PHAs. In the Crosby facility’s development of its worst-case process safety scenarios,
Arkema managers evaluated a variety of hazard categories including fires, explosions, chemical
releases, and extreme weather events.a The weather events documented by Arkema managers
included a range of natural disasters, b but did not list flooding.

5.6.

ARKEMA STATEMENTS

179. In its written post-incident statements, Arkema stressed that the company’s history in Crosby dates
to 1960. In its 57-year history at the Crosby site, many hurricanes and tropical storms affected thefacility. Arkema shared that some of its current staff members have been at the Crosby facility for
40 years and that their experience in the worst earlier floods was that pickup trucks could still drivearound the site. These long-term employees identified Tropical Storm Allison [67] in 2001 as theprevious high-water benchmark for flooding at the Crosby facility. Arkema also said that recent
hurricanes, including Ike in 2008 [68] and Rita in 2005 [69], made landfall closer to Crosby thanHarvey, and although both Ike and Rita produced significant rainfall, they did not result in similar
flooding.
180. The CSB notes that none of the previous storms cited by Arkema exceeded the rainfall produced by
Hurricane Harvey, but Hurricane Rosa and an unnamed storm in 2015 produced significantly morerain near the Arkema Crosby facility than either Ike or Rita. The highest two-day rainfall totals
recorded near the Arkema Crosby facility were as follows:ab•

Hurricane Rosa (1994): 23 inches;•

Tropical Storm Allison (2001): 2.7 inches;•

Hurricane Rita (2005): 3.8 inches;•

Hurricane Ike (2008): 6.5 inches; and•Hurricane Harvey (2017): 26.5 inches.

Extreme weather events include hurricanes, droughts, tornadoes, snowstorms, and flooding [240].
These natural disasters included tornadoes, lightning, and excessive heat, among other events.

86

CSB · Investigation Report181. Before Hurricane Harvey, based on Harris County Flood Control District rainfall gauge data, themost recent comparable rainfall event at the Arkema Crosby facility was the October 2015
unnamed storm, with a two-day rainfall total of 13 inches [29]. a
182. Arkema records indicate that the Crosby plant flooded during the October 2015 rain storm, but the
Low Temperature Warehouses and emergency generators did not flood during the event. During
this storm, Arkema experienced no releases or fires from the Crosby facility.

a

Peak rainfall for the 2015 storm occurred on October 31, 2015.

CSB · Investigation Report876. FLOOD PLANNING GUIDANCE
183. Several different sources offer guidance for facilities on how to address flood hazards.
Nonetheless, even if Arkema had applied this guidance before Hurricane Harvey, the incident likely
would not have been averted. This conclusion suggests that more robust flood hazard guidance isneeded in the U.S.

6.1.

AMERICAN SOCIETY OF CIVIL ENGINEERS

184. The American Society of Civil Engineers (ASCE) published Flood Resistant Design andConstruction, ASCE 24, as a standard for the siting, design, and construction of buildings andstructures in flood hazard areas [70, p. 1]. a ASCE 24 includes, among other building types,
commercial, residential, industrial, educational, healthcare, and critical facilities [70, p. 1]. ASCE
24 establishes Flood Design Classes based on building use and the potential risk to the public or
disruption to the community, as shown in Table 5 [70, p. 8].
Table 5. Flood Design Classes. Each ASCE Flood Design Class is a function of building use andpotential risk to the public [70, p. 8].

185. Flood Design Class 4 includes “buildings that pose a substantial risk to the community at large inthe event of a failure, disruption of function, or damage by flooding [70, p. 8].” Flood Design Class
4 also includes facilities such as the Arkema plant in Crosby, “that manufacture, process, handle,
store, use, or dispose of such substances as hazardous fuels, hazardous chemicals, or hazardous
waste [70, p. 8].”186. ASCE 24 specifies the required elevation and the additional height above the base flood elevation
as a function of both the Flood Design Class and the nature of the flood hazard area [70, p. 4].
Flood Design Class 4 buildings and structures must be elevated or protected to the base flood
elevation plus two feet or to the 500-year flood elevation [70, p. 4]. Because the base flood
elevation of the Arkema Crosby facility is 52 feet, applying ASCE 24 to new construction requires
using flood damage resistant materials for all buildings and structures below 54 feet and establishes
that utilities and equipment must be elevated above 54 feet [70, p. 4]. On the basis of floodwatera

ASCE 24 states the minimum requirements and applies to buildings and structures that are subject to building code
requirements. ASCE is a referenced standard in the International Codes® [70, p. 1].

88

CSB · Investigation Reportlevel produced during Hurricane Harvey, this standard would have been insufficient to protect the
Low Temperature Warehouses and their backup systems.

6.2.

CENTER FOR CHEMICAL PROCESS SAFETY

187. The American Institute of Chemical Engineers’ Center for Chemical Process Safety (CCPS) is a
corporate membership organization that identifies and addresses process safety needs in thechemical, pharmaceutical, and petroleum industries. CCPS publishes a series of guidance
documents that are widely used in these industries.

6.2.1. GUIDELINES FOR SAFE WAREHOUSING OF CHEMICALS
188. In its book Guidelines for Safe Warehousing of Chemicals, CCPS states that chemical storage
creates “the potential for hazards including injuries, illness, environmental damage, property
damage, and business interruption” [71, p. 1].” CCPS also notes that natural disasters, including
floods, can triggers these hazards [71, p. 1]. CCPS cautions companies to evaluate these risks,stating, “… it is paramount that the risk of chemical warehousing be fully understood andappropriate steps taken to prevent or mitigate losses [71, p. 1].”189. CCPS identifies flooding as having the potential to release chemicals into the environment [71, p.
59]. To understand flood risk, companies are directed to FEMA resources, including Flood
Insurance Studies and Flood Insurance Rate Maps. CCPS observes, “The 100-year flood interval
and its associated flood elevation are the most widely used criteria for estimating flood potential”[71, p. 59].
190. CCPS emphasizes the importance of a comprehensive warehouse risk management strategy,
including an emergency plan that addresses emergency scenarios [71, p. 135]. CCPS identifies
decomposition reactions that create chemical releases among the potential scenarios that company
emergency plans should address [71, p. 135]. In addition, CCPS recommends that emergency
planning efforts consider the possibility of chemical releases caused by flooding [71, p. 136].
191. In Guidelines for Safe Warehousing of Chemicals, CCPS provides companies with design andemergency protection guidance to mitigate flood damage, including the following:a•Designing warehouse floors that are higher than the base flood levels;•

Building levees or flood walls with appropriate freeboard; a•Providing watertight closures, flood doors, and shields over windows; and“Freeboard is a factor of safety usually expressed in feet above a certain flood level, and is often applied to critical facilities.
Freeboard (commonly 1-3 additional feet) compensates for the many unknown factors that could contribute to how highfloodwater can rise, such as wave action, constricted bridge openings, and the hydrological effect of urbanization in thewatershed [228, p. 1].”

CSB · Investigation Report89•

Removing chemicals that require refrigeration [71, p. 106].

192. The CCPS guidance recommends building “above base flood levels” which likely would have beeninterpreted as higher than the 100-year flood elevation. Lacking specific criteria on how far above
base flood level companies should elevate their critical equipment, however, this CCPS guidancemight not have been sufficient to prevent the Arkema Crosby incident.

6.2.2. GUIDELINES FOR SAFE STORAGE AND HANDLING OF REACTIVE MATERIALS
193. In its book Guidelines for Safe Storage and Handling of Reactive Materials, CCPS offers guidance
for reactive chemicals, which are self-reactive materials that decompose, or break down into
simpler molecules [13, p. 2]. CCPS specifically addresses organic peroxides, noting that thesechemicals “have particular stability problems that make them among the most hazardous ofindustrial chemicals [13, p. 3].” Organic peroxides “may decompose at an accelerating rate until itproceeds in an uncontrollably high rate of reaction (“runaway” decomposition reaction) [13, p. 3].”194. CCPS recommends that equipment designers “consider the use of existing codes and standards as
the starting point from which to design a safe facility” [13, p. 138]. This is because “Codes andstandards embody a wealth of technical know-how and lessons learned from past experience andprevious incidents [13, p. 138].” CCPS states that many codes address hazardous chemical
characteristics and management systems “such as emergency planning and response” [13, p. 138].
195. CCPS describes a number of the organic peroxide decomposition hazards that are applicable to the
Arkema Crosby incident, including the following:“The instability of organic peroxides requires special precautions in theirstorage and handling [13, p. 219].”“The primary hazards involved in the safe storage and handling of organic
peroxides are thermal sensitivity and, in many cases, flammability or
combustibility [13, p. 219].”“Most will burn vigorously once ignited, and some are susceptible todetonation if not diluted (such as dry benzoyl peroxide) or if confinedwhen decomposition occurs [13, p. 219].”
196. CCPS also described the decomposition characteristics of organic peroxides, saying:
Organic peroxides also all exhibit sensitivity to heat, which increases withthe reactivity of the peroxide. Organic peroxides are constantly
undergoing decomposition, at a rate that is dependent on the temperatureof the material. When thermal energy available from the heat ofdecomposition exceeds the rate of heat dissipation to the surroundings, theincreasing temperature accelerates the decomposition of the remaining
peroxide. This may proceed out of control in a characteristic "runaway
reaction" decomposition. The danger of runaways is increased for some90

CSB · Investigation Reportperoxides, such as cumene hydroperoxide, because the decomposition is
autocatalytic; i.e., the decomposition products catalyze further
decomposition and cause the reaction to self-accelerate [13, p. 219].
197. CCPS recommends that companies consider elevating the storage of reactive chemical containers if
the possibility of flooding exists [13, p. 156], but does not give specific guidance on how highproducts must be raised above the anticipated level of floodwater.

6.2.3. GUIDELINES FOR TECHNICAL PLANNING FOR ON-SITE EMERGENCIES
198. In its book Guidelines for Technical Planning for On-Site Emergencies, CCPS provides companies
with guidance on developing emergency plans [72, p. 153]. Emergency planning guidance“included identifying credible incidents, evaluating resources, devising response tactics, organizing
properly, and defining necessary resources” [72, p. 153]. In addition, CCPS includes guidance on
developing a number of hazard-specific procedures, including procedures for both hurricanes andflooding [72, pp. 172-177].
199. CCPS recommends that companies develop a flood procedure whenever a facility lies in afloodplain, is subject to potential flooding, or has a history of flooding [72, p. 177]. CCPS directs
companies to seek available flood studies that might offer insights into the level of flooding to be
expected [72, p. 177].

6.3.

FEDERAL EMERGENCY MANAGEMENT AGENCY

200. The Federal Emergency Management Agency (FEMA) recommends that emergency power systems(and the equipment they supply) within critical facilities, such as the Arkema Crosby facility,
should be protected against the highest anticipated flood elevation, including the following:•

Base flood elevation plus two feet;•

Locally adopted design flood elevation plus one foot; and•500-year flood elevation plus one foot [73, pp. 6-12].

201. As detailed previously, the water level during Hurricane Harvey was more than two feet above thebase flood elevation. On the basis of this water level, the FEMA guidance would have been
insufficient to protect the Low Temperature Warehouses and their backup systems.

6.4.

EPA FACILITY DESIGN PRACTICE

202. The EPA established facility design practices to enhance the resilience of its buildings against
extreme weather events [74]. For critical buildings in flood hazard areas, EPA builds three feetabove the 100-year flood elevation [74].

CSB · Investigation Report91203. If Arkema had used this guidance before Hurricane Harvey, it possibly could have prevented theincident. This EPA document, however, is intended as guidance only for EPA buildings and is notintended as general industry guidance.

6.5.

FM GLOBAL

204. FM Global published Creating a Flood Emergency Response Plan to offer flood preparation
guidance to companies [75]. FM Global is convinced that being prepared for flooding can reduce
flood damage and business disruption [75, p. 1]. FM Global also believes that the key to success isdevoting an adequate amount of time to developing a flood plan before the flood [75, p. 1].
205. In addition to enhancing safety, flood preparations represent a good business decision. FM
Global’s loss history shows that “facilities with well-organized flood emergency response plans
have nearly 70 percent less damage, and resume operations sooner than those locations without aflood emergency response plan, or an inadequate one, in place [75, p. 1].”206. According to FM Global’s flood preparation guidance, elevating critical equipment constitutes a
key activity to reduce flood risk because relocating key equipment to higher elevations makes a“major―and permanent―impact” if flooding occurs by reducing company reliance on humanintervention during a flood [75, p. 1].
207. FM Global recommends, among other flood preparation guidance, that companies take thefollowing actions:•

Evaluate flood risk to understand potential exposure;•

Ensure that a reliable flood warning system is in place;•

Balance the flood warning time with the flood response time―balance the time available toactivate flood response actions against the time needed for the staff to implement thoseactions;•

Identify and implement changes that permanently reduce flood risk, such as elevating
critical equipment or installing permanent flood barriers to keep out floodwater;•

Establish effective emergency actions, including erecting temporary water barriers,
relocating critical inventory, or moving portable high-value equipment; and•Develop a written flood plan, train employees in its use, and periodically conduct a dry runof the entire plan [75, p. 2].

208. The FM Global guidance also identifies the following other features of a sound flood plan:•

92

Establishment of who has the authority to activate the plan, redirect production resources,
and shut down operations;

CSB · Investigation Report•

Written procedures to safely shut down and isolate electrical equipment, and to raise or
relocate key materials and critical equipment;•

Reliable methods to prevent water from entering key buildings or areas;•

Means to take care of employees and their families if the flood is prolonged;•

Focused reliance on employees whose homes are less likely to be affected during a flood;and•Periodic review and updating of the flood plan to address changes in equipment, people, orbusiness activities [75, pp. 2-3].

209. The FM Global guidance is general and Arkema could not have effectively used it to prevent theincident at the Crosby facility.

6.6.

UNITED KINGDOM ENVIRONMENT AGENCY

210. In the U.K., the Environment Agency published Preparing for Flooding – A guide for sites
regulated under EPR and COMAH as guidance to help regulated facilities conduct flood planningto comply with their environmental permits and regulations [76]. a, b Similar to Harris County, theU.K. experiences flooding as a common event. The Environment Agency flood preparation
guidance recommends that regulated companies take the following actions:•

Determine whether the site is in an area at risk of flooding;•Be aware if flooding is imminent;•

Understand flood warnings;•

Obtain site topography information and more detailed flood modeling;•

Prepare a flood plan; and•Improve the site’s flood resilience by:a. Taking steps to protect the operation from flooding; andb. Applying protective measures to stop, slow, or deflect floodwater including:a

EPR is an initialism for Environmental Permitting Regulations in England and Wales [147]. COMAH is an initialism forControl of Major Accident Hazards – United Kingdom chemical industry regulations [242]. The Health and Safety Executive(HSE), the Environment Agency (EA), and the Scottish Environmental Protection Agency (SEPA) are the United Kingdom’s
competent authorities responsible for the enforcement of these regulations [148], [149], and [150], respectively.
b
The Environment Agency also published Would your business stay afloat? as a more general guide for businesses to prepare forflooding [219].

CSB · Investigation Report93

i. Using drainage systems with excess capacity;
ii. Employing drainage techniques such as retention ponds;
iii. Raising the ground or providing raised platforms; andiv. Ensuring effective maintenance of drainage and flood management
systems [76].
211. For chemical product warehouses, the Environment Agency recommends moving vulnerable
products (such as organic peroxides) above the predicted floodwater elevation. In addition, theEnvironment Agency encourages companies to use flood resistance measures, such as removableflood barriers. The Environment Agency also directs companies to a website that lists flood
defense product options and suppliers [76, pp. 1-4].
212. The Environment Agency guidance informs companies that flood planning should be part of theirsite accident or emergency plans [76, p. 2]. The guidance also suggests that a good flood plan will
include steps to protect workers, safeguard hazardous processes, and secure materials [76, p. 2]. In
addition, companies should be able to implement the plan within the time available before the site
floods [76, p. 2].
213. The Environment Agency flood planning guidance cautions companies to recognize and consider
that flood warnings might result in limited response time and that all flood mitigation measures may
fail [76, p. 2].
214. The Environment Agency flood planning guidance states, “An effective plan will be based on athorough understanding of the risks of flooding on specific areas of the plant and operations” [76, p.
3]. The Environment Agency guidance also recommends that companies complete a “flood Hazard
and Operability (Hazop) study,” especially for sites that fall under the U.K. Control of Major
Accident Hazards (COMAH) regulations [76, p. 3].
215. Of relevance to the Arkema Crosby incident, the Environment Agency flood preparation guidance
specifically discusses key utilities, such as electrical power and liquid nitrogen. The flood
preparation guidance states:
You should make sure that electricity (including on-site transformers andsubstations), gas, steam, heating, cooling, and water supply systems areabove predicted flood levels, are flood resilient or can be safely isolatedor switched off before flooding. As the loss of utilities may be for an
extended period, you should consider the installation of backup systems
for critical equipment [76, p. 5].
216. Also pertinent to the Arkema Crosby incident, the Environment Agency flood preparation guidance
recommends that companies move vulnerable products in warehouses above the height of thepredicted floodwater [76, p. 4].

94

CSB · Investigation Report217. When a company is developing a flood plan, the Environment Agency guidance recommends
considering the following factors:•

Hazards created by floodwater inundating equipment;•

Both short-term and long-term loss of utilities, such as the electric power supply;•

Loss of critical safety equipment;•

Capability of performing manual operations, taking into account hardware, operatingprocedures, competence, and training; and•Required time to safely shut down operations, relocate personnel, and secure chemicals [76,p. 3].

218. The Environment Agency flood plan guidance also stresses the importance of taking actions when
forecasts predict flooding, including identifying proper actions and needed information. The
Environment Agency states that a good flood plan will include the following components:•

Assignment of flood response tasks to trained workers;•

Identification of sources of flood warnings, weather predictions, and floodwater level;•

Development of trigger points―such as amount of rainfall, river levels, and flood
warnings―that initiate predefined actions such as shutting down operations, isolating
equipment, or evacuating personnel;•

Design details, including operation of flood defenses;•

Contact information and contractual arrangements for the supply of emergency resources –such as pumps, electrical power generators, and cleanup equipment; anda. Post-flooding activities, including removal of floodwater; verification of plant andequipment integrity; and physical inventory checks to identify any loss of polluting,hazardous, or radioactive material [76, p. 3].

219. The Environment Agency flood planning guidance also recommends periodic training and reviews
to prepare staff members for their responsibilities and to ensure that required actions are realistic
given the likely time limitations and few resources that might be available during extreme weather[76, p. 3].

6.7.

CHEMICAL INDUSTRIES ASSOCIATION

220. In its report Safeguarding Chemical Businesses in a Changing Climate – How to Prepare a Climate
Change Adaptation Plan, the Chemical Industries Association, a United Kingdom (U.K.) chemical

CSB · Investigation Report95industry trade association, a acknowledged that climate projections show U.K. chemical facilities
facing an increased risk of more frequent and severe flooding because of heavy rainfall [77, p. 4]. b
221. The report states that preparing for extreme weather events makes good business sense by enabling
continued operations as weather risks increase [77, p. 7]. Similar to weather events in the U.S.,
flooding is the most frequently occurring natural disaster in the U.K. [77, p. 7]. Unlike the U.S.,
however, the U.K. specifically requires chemical facilities in the U.K. to prepare for flooding aspart of their environmental protection systems [77, p. 7].
222. As an initial step in assessing flood risk, the Chemical Industries Association recommends thatcompanies consider the following questions:•

Is the site susceptible to flooding?

•Has the site flooded before?

•

Will climate change affect the risk of future flooding [77, p. 7]?

223. The report reviewed a 2013 flooding event that affected three facilities. Key lessons from the event
included a recognition that flood defenses can fail and that putting a flood plan in place is essential[77, pp. 12-13].

6.8.

UNITED NATIONS DISASTER RISK REDUCTION

224. In March 2015, the United Nations (UN) issued a document dealing with global disaster risk
management to assist in reducing existing risks and to strengthen resilience c in the face of bothnatural and human induced hazards [78].
225. Among other conclusions, the UN report states:[From 2005 to 2015], disasters have continued to exact a heavy toll and,as a result, the well-being and safety of persons, communities andcountries as a whole have been affected. Over 700 thousand people havelost their lives, over 1.4 million have been injured and approximately 23
million have been made homeless as a result of disasters. Overall, morethan 1.5 billion people have been affected by disasters in various ways,
with women, children, and people in vulnerable situationsaChemical Industries Association [192]. The Chemical Industries Association runs a Responsible Care program in the U.K.
covering issues of health, safety, environment, and security [77, p. 10]. In the U.S., the American Chemistry Council (ACC)
requires its member companies, such as Arkema [232], to adhere to Responsible Care [233].
b
The report was prepared by a partnership between the Chemical Business Association [193], the Chemical Industries
Association [192], the Non-Ferrous Alliance [194], and the Environment Agency’s Climate Ready Support Service [196], [77].
Note – the Environment Agency ended its Climate Ready program in March 2016 [195].
c
The United Nations defines resilience as follows: “The ability of a system, community or society exposed to hazards to resist,absorb, accommodate, adapt to, transform and recover from the effects of a hazard in a timely and efficient manner, including
through the preservation and restoration of its essential basic structures and functions through risk management [220].”96

CSB · Investigation Reportdisproportionately affected. The total economic loss was more than $1.4
trillion. In addition, between 2008 and 2012, 144 million people weredisplaced by disasters [78, p. 10].
It is urgent and critical to anticipate, plan for and reduce disaster risk inorder to more effectively protect persons, communities, and countries,
their livelihoods, health, cultural, heritage, socioeconomic assets andecosystems, and thus strengthen their resilience [78, p. 10].
226. The UN report found that the drivers for disaster risk have a local, national, or global scope, but therisks with local characteristics must be understood to reduce disaster risk [78, p. 13]. The reportfound that mitigating disaster risk before an incident is more cost-effective than reliance on postdisaster response and recovery [78, p. 13]. To reduce risk before a disaster, relevant data should becollected and analyzed. These data, including risk maps, should be disseminated to appropriate
decision-makers, the public, and communities at risk of exposure to the disaster [78, p. 15].
Baselines should be periodically assessed to evaluate disaster risks [78, p. 14]. The report notedthat during post-disaster recovery, however, it is critical to reduce future disaster risk by “Building
Back Better” and increasing disaster risk education and awareness [78, p. 14].
227. The UN recommended that local and national governments adopt risk reduction strategies and plans
aimed at preventing incidents, reducing existing risk, and strengthening resilience [78, p. 16].
Governments should also “encourage” the establishment of mechanisms and incentives to ensurecompliance with existing regulations and to update regulations so that they promote an adequate
focus on disaster risk management [78, p. 17].
228. This UN document offers only general guidance and does not provide any prescriptive requirementsthat Arkema could have used before Hurricane Harvey to prevent the incident.

CSB · Investigation Report97

7. REGULATORY ANALYSIS
7.1.

FLOOD HAZARDS

229. As the previous section has shown, there is a lack of robust flood risk guidance available to industry
to help prepare companies such as Arkema for extreme weather events. The CSB recommendation
to CCPS is intended to help close this gap.

7.1.1. UNITED STATES APPROACH
230. Similar to weaknesses in existing industry guidance, Federal safety regulations also lack specificrequirements or detailed guidance on how companies should evaluate and address extreme weather
events, such as flooding.

7.1.1.1. OSHA PROCESS SAFETY MANAGEMENT STANDARD
231. Arkema considers its organic peroxide manufacturing process at the Crosby facility as covered by
the OSHA PSM standard a because of the chemical quantities used or stored.b In addition, Arkema
views one of its organic peroxide storage buildings as meeting the chemical quantity requirements
for coverage under the OSHA PSM standard. Arkema did not consider its seven Low Temperature
Warehouses as covered by the PSM standard. As a stated “best practice,” however, Arkema applies
its PSM program to all areas of the facility.
232. The Clean Air Act Amendments of 1990 required OSHA to promulgate the PSM standard, alongwith the concurrent requirement for the EPA to issue its Risk Management Plan regulations [79].
OSHA implemented the PSM standard with the primary objective of preventing unwanted releasesof highly hazardous substances at locations storing such substances in quantities above theestablished threshold, with special emphasis on protecting locations where workers could be
exposed to the serious hazards posed by such chemicals. PSM and its 14 elements focused ontrying to bring a systematic approach to managing process safety [79]. c PSM uses bedrock process
safety principles designed to make entire chemical processes safe, as formalized in the regulatory
requirements, such as the requirements to perform a process hazard analysis, establish soundoperating procedures, ensure adequate employee training and involvement, maintain the mechanicalintegrity of all process equipment, and ensure a satisfactory level of emergency preparedness in theevent of an unwanted release. da

29 C.F.R. § 1910.119.
The PSM standard covers chemicals that have been deemed hazardous either because of their chemical composition andquantity (listed in Appendix A) or because of their flammability characteristics (flash point below 100 °F). The Arkema Crosby
facility had PSM-covered (sufficient quantities of) chemicals that were either listed in Appendix A or had a flash point below
100 °F.
c
29 C.F.R. § 1910.119.
d
29 C.F.R. § 1910.119.
b

98

CSB · Investigation Report233. OSHA considers a strength of its PSM standard to be its performance-based nature [80]. For
example, OSHA asserts that it provides many examples of process safety information throughguidance that is not specifically called out in the PSM standard [80]. Furthermore, although floodrelated documents such as FEMA flood maps and Flood Insurance Studies are not specifically
identified as process safety information, OSHA contends that for facilities at risk of flooding, thisinformation could be considered process safety information, prompting the need for a managementof-change review [80]. In addition, OSHA maintains that although the PSM standard does notdefine facility siting requirements by design, that does not mean that consideration of flood risk or
flood hazards are not required as part of a company’s facility siting review [80]. The PSM standard
does not, however, contain an express regulatory requirement for companies to consider flood
insurance maps and related studies as process safety information or to consider flood risk or flood
hazards in their PHAs or facility siting reviews. In addition, the CSB investigation did not identify
any current and applicable OSHA guidance on flood risk or flood hazards.
234. OSHA PSM guidance provided to industry on PHAs states that a PHA should analyze “external
factors that might affect the process [81].” While companies may analyze flood risk in their PHA
as part of external factors, this limited guidance may not prompt a PHA team to have a specificdiscussion or evaluation of flooding or flood risk.

7.1.1.2. EPA RISK MANAGEMENT PROGRAM
235. Arkema considers two of the chemicals at the Crosby facility as covered by EPA’s Risk
Management Plan (RMP) rule a―sulfur dioxide and isobutylene. Arkema does not consider the
Low Temperature Warehouses to be covered by the RMP rule. The Arkema Crosby facility
submitted its most recent RMP to the EPA in 2014.
236. The EPA RMP rule constituted EPA’s efforts aimed at chemical accident prevention. The RMP
rule requires a facility to estimate not only the potential impacts of a worst-case release but also
alternative, more likely scenarios that could impact the public. Depending on the type of facility,
the rule requires a facility to: analyze potential hazards of its covered processes; train employees;
document operating procedures; maintain mechanical integrity of covered processes; investigate
accidental release and other events; and periodically reassess its accident prevention program. b
Facilities must coordinate with emergency responders on steps to take in the event of an accident,
and summarize all compliance steps in the facility’s RMP. c The RMP rule also requires owners andoperators of stationary sources with threshold quantities of regulated substances onsite to registerand provide the government with certain information. Specifically, companies must provide theirown worst-case offsite consequence analysis of an accidental release of those regulated substances.
Companies also must document a number of data points about both the nature and extent of thechemicals on site, as well as accident history data, pertinent company programs intended to keepa

40 C.F.R. §§ 68.150-68.195.
40 C.F.R. Part 68.
c
40 C.F.R. Part 68.
b

CSB · Investigation Report99those chemicals safe from release, and emergency response information in the event of an
accidental release. a237. When the EPA promulgated the RMP rule, the agency intended for the PHA requirement to parallel
the requirements found in the OSHA PSM rule. The EPA, in response to comments about the new
RMP rule in 1996, provided the following guidance on the RMP PHA requirement: “As part of aproperly conducted PHA, sources would normally consider whether a process is vulnerable todamage caused by external events, such as earthquakes, floods, high winds, and evaluate thepotential consequences [if] such events damaged the integrity of the process [82].” The EPA
general RMP guidance for Program 2 b facilities states that facilities should consider “reasonably
anticipated external events as well as internal failures. If you are in an area subject to earthquakes,
hurricanes, or floods, you should examine whether your process would survive these natural events
without releasing the substance [83, pp. 6: 10-11].”238. To avoid conflicting regulations, EPA noted: “To ensure consistency with OSHA PSM, EPA has
adopted OSHA's language on PHAs. Therefore, EPA has not added language on consideration of
external events to the rule. EPA agrees, however, that sources must consider the hazards created byexternal events in any appropriate risk management program. As part of a properly conducted
PHA, sources would normally consider whether a process is vulnerable to damage caused byexternal events, such as earthquakes, floods, high winds, and evaluate the potential consequences ifsuch events damaged the integrity of the process. (1996 RMP RTC, 9-23) [82] and [84].”239. EPA further explained: “you should consider reasonably anticipated external events as well asinternal failures. If you are in an area subject to earthquakes, hurricanes, or floods, you should
examine whether your process would survive these natural events without releasing the substance.
RMP General Guidance, pages 6-10 to 6-11 [83] and [84].”240. EPA also notes that in examining a company’s processes, “considerations are chemical and processdependent and site-specific in nature, and therefore the regulations require facilities to determine
the measures needed to address such hazards at their facility, using good industry practices andrecognized and generally accepted good engineering practices (RAGAGEP), such as consensusab

40 C.F.R. §§ 68.150-68.195.
Under RMP, Arkema is a Program 3 facility. Under the RMP rule, Program 2 facilities are those that do not meet the eligibility
requirements for Program 1 and Program 3 facilities. 40 C.F.R. § 68.10(c). Program 1 facilities are those that meet thefollowing requirements: “For the five years prior to the submission of an RMP, the process has not had an accidental release ofa regulated substance where exposure to the substance, its reaction products, overpressure generated by an explosion involving
the substance, or radiant heat generated by a fire involving the substance led to any of the following offsite: (i) Death; (ii)
Injury; or (iii) Response or restoration activities for an exposure of an environmental receptor; (2) The distance to a toxic or
flammable endpoint for a worst-case release assessment conducted under subpart B and §68.25 is less than the distance to any
public receptor, as defined in §68.30; and (3) Emergency response procedures have been coordinated between the stationary
source and local emergency planning and response organizations.” 40 C.F.R. § 68.10(b). Program 3 facilities are those thatmeet the following requirements: “A covered process is subject to Program 3 if the process does not meet the requirements ofparagraph (b) of this section, and if either of the following conditions is met: (1) The process is in NAICS code 32211, 32411,
32511, 325181, 325188, 325192, 325199, 325211, 325311, or 32532; or (2) The process is subject to the OSHA process safety
management standard, 29 CFR 1910.119. (e) If at any time a covered process no longer meets the eligibility criteria of its
Program level, the owner or operator shall comply with the requirements of the new Program level that applies to the process
and update the RMP as provided in §68.190. (f) The provisions of this part shall not apply to an Outer Continental Shelf(“OCS”) source, as defined in 40 CFR 55.2.” 40 C.F.R. § 68.10(d).

100CSB · Investigation Reportindustry codes and standards [84].” As noted above, however, effective guidance from consensus
industry codes and standards is lacking with respect to flood risk. As such, guidance must be
developed to meet the thrust of EPA’s original position on this topic, which rested on limited
OSHA guidance and weak or non-existent industry standards.
241. Despite Federal safety requirements covering the hazardous substances specified in both regulatory
frameworks and despite the potential for flood risk to be analyzed under existing terms within theexisting regulatory structure, no clear and specific regulatory requirement calls for flood risk to beassessed in relation to process safety under the regulation language in either the PSM standard or
the RMP rule.

7.1.2. EUROPEAN UNION APPROACH
242. In contrast to the U.S. approach, in the European Union, major chemical incident risks are regulatedby the Seveso Directive, which applies to industrial activities that use, handle, or store specifichazardous substances [85, p. 53]. The Seveso Directive requires some facilities that manufacture orstore large quantities of hazardous chemicals to generate a safety report demonstrating the facility
has a major-accident prevention policy and that the incident scenarios have been identified and therisks mitigated [85, p. 53]. The Seveso Directive requires facilities to address increased risk arisingfrom the geographical location of a plant. If a facility that manufactured organic peroxides, such as
Arkema’s Crosby facility, was physically located in the European Union and was therefore covered
by Seveso, the safety report that would be required under the Seveso Directive could have included
risks attributable to flooding from hurricanes.
243. After a number of incidents, the European Union updated the Seveso Directive in 2012 to address
extreme weather risks more explicitly. The Seveso Directive now requires that companies regularly
identify and evaluate environmental hazards, such as floods and earthquakes in the facility’s safety
report [85, p. 54].

7.2.

REACTIVE HAZARDS

244. The August 2017 incident at the Arkema Crosby facility was a reactive incident. As defined, areactive incident is a sudden event involving an uncontrolled chemical reaction―with significant
increases in temperature, pressure, or gas evolution―with the potential to cause serious harm topeople, property, or the environment [86, p. 103]. In September 2002, the CSB completed its major
hazard investigation, entitled Improving Reactive Hazard Management [86]. The CSB concluded
that better management of reactive hazards is necessary to prevent reactive incidents [86] and [87,p. 4].
245. In Improving Reactive Hazard Management, the CSB notes:
When developing the list of substances, EPA considered only the inherent
characteristics of a chemical that indicate a severe threat due to exposure.
Well-defined criteria were used for toxicity and flammability. However,

CSB · Investigation Report101because of the complexities of site-specific factors and process conditions,
EPA was unable to determine any inherent characteristic as an indicatorof reactivity. EPA concluded that there was “insufficient technicalinformation for developing criteria for identifying reactive substances.”
Consequently, the January 1994 RMP list of 130 chemicals does notcontain any substances listed due to reactive hazards [86, p. 60].
246. As the CSB’s 2002 Improving Reactive Hazard Management study found, “More than half of theaccidents involved chemicals that [similar to organic peroxides] are exempt from OSHA and EPA
process safety rules.” a The study concluded that “the EPA Accidental Release Prevention
Regulations (40 CFR 68) have significant gaps in coverage of reactive hazards [86, p. 87].”247. As a result, the CSB issued Recommendation Number 2001-1-H-R3 to the EPA to improvecoverage and regulation of reactives. It states: “Revise the Accidental Release Prevention
Requirements, 40 CFR 68, to explicitly cover catastrophic reactive hazards that have the potential
to seriously impact the public, including those resulting from self-reactive chemicals andcombinations of chemicals and process-specific conditions. Take into account therecommendations of this report to OSHA on reactive hazard coverage. Seek congressional
authority if necessary to amend the regulation [86].”248. EPA did not act on the CSB’s recommendation, as presented. Instead, EPA took a number of othersteps that it believed helped to strengthen the management of reactive hazards, which included
participating in a 2003 roundtable meeting, revising the agency’s accident reporting system toimprove collection of reactives data, collaborating with CCPS in producing a 2003 publication on
managing chemical reactivity hazards, and publishing two safety alerts on reactives in 2004 and2005. EPA also informed the CSB that it would continue to use its authority under the Clean Air
Act’s General Duty Clause to apply RMP requirements to facilities producing, processing, handlingor storing “an extremely hazardous substance.” The CSB, however, found these alternative
measures inadequate, believing the regulatory changes as proposed in Recommendation 2001-1-HR3 remained necessary, and voted to designate the recommendation as “Open – Unacceptable
Response [88].” The CSB is now reiterating this recommendation to EPA to help prevent future
reactive chemical incidents. First and foremost, the CSB continues to believe that reactives should
be covered by RMP in the manner originally recommended. Second, and more germane to the
Arkema incident, if reactives had been covered by RMP, and Arkema had conducted its required
off-site consequence analyses (both worst-case and alternative scenarios) in accordance with RMP
requirements, the company may have identified the hazards associated with the Crosby site’s flood
vulnerabilities, and the follow-on threats to the company’s organic peroxides stored onsite, throughthat additional level of risk-based thought process.

a

Although OSHA or EPA rules might not have covered the specific chemical involved in these accidents, other chemicals usedin the process might have resulted in the process being covered by these Federal safety regulations.

102

CSB · Investigation Report8. HOW COMPANIES CAN EVALUATE FLOOD RISK AT THEIR FACILITIES
249. Given the lack of flood risk guidance from OSHA, EPA, or existing chemical industry standards,
companies might not have a good practice approach for evaluating the flood risk at their facilities.
250. In response to the incident, Arkema commissioned a site elevation survey for its Crosby facility tounderstand the elevation for all relevant points at the facility as well as a hydrological study tounderstand the likely flooding conditions during extreme weather events, such as hurricanes.
Arkema will be able to use this data to evaluate the risks for a number of floodwater severity levels
to help prevent future loss of refrigeration leading to organic peroxide product decomposition.
251. In 2007, FEMA updated flood documents for the region containing the Arkema Crosby facility.
FEMA changed the flood designation map covering the area where the Low Temperature
Warehouses containing organic peroxides are located; the warehouses are no longer outside of the
500-year flood zone but rather sit inside the 100-year zone. FEMA also established the base flood
elevation at 52 feet. Arkema did not incorporate this new information into its process safety
management systems and it did not evaluate the potential flood risks.
252. Process safety information broadly describes all of the information necessary for companies to
identify and understand the process safety hazards at their facilities. a Although OSHA identified
minimum process safety information requirements―including data such as “design codes andstandards employed”―OSHA did not specifically identify FEMA flood maps or Flood InsuranceStudies as process safety information. b Furthermore, no other subheading is listed for process
safety information that could fairly be read to capture the inclusion of flood risk for consideration.
Despite this, OSHA’s position is that the agency could consider FEMA flood maps or Flood
Insurance Studies as required process safety information, especially for facilities at risk of flooding[80].
253. If companies do not view flood maps or Flood Insurance Studies as process safety information,these documents might not be reviewed as part of process hazard analyses or during facility siting
reviews. Changes to these important flood information documents might not prompt companies toconsider the need for a management-of-change review. As a result, company process safety
management systems might not be including important flood risk information. In this case, theArkema checklist used for collecting process safety information did not include flood maps or
Flood Insurance Studies.
254. Assessing flood risk during facility siting reviews represents one approach that companies might
consider when evaluating the potential for flooding to initiate process safety hazards. Chemical
manufacturing facilities covered by either the OSHA PSM standard or the EPA RMP rule areab

29 C.F.R. § 1910.119(d).
29 C.F.R. § 1910.119(d).

CSB · Investigation Report103required to evaluate facility siting (stationary source siting) as part of the process hazard analysis
component within their process safety management systems. a
255. Neither regulatory agency, however, defined the specific requirements that companies mustcomplete when evaluating facility siting hazards. As such, CSB’s investigation was unable toidentify any existing requirements for companies to evaluate flood risk during facility siting
reviews, and no such evaluations were ever documented for the Crosby site. OSHA’s position isthat the PSM standard does not define facility siting requirements by design, but that does not meanthat consideration of flood risk or flood hazards are not required as part of a company’s facility
siting review [80].
256. Industry guidance on facility siting generally focuses on assessing and managing explosion, fire,
and toxic chemical release hazards that could threaten people occupying buildings in close
proximity to the process plants [89]. This focus stems from incidents such as the 2005 explosion at
the BP refinery in Texas City, Texas that killed 15 workers in or around trailers located near theisomerization unit [90]. In response to CSB’s findings regarding the BP Texas City incident,
industry groups like the American Petroleum Institute (API) and the Center for Chemical Process
Safety (CCPS) have developed guidance documents to help assess facility siting hazards [89].
257. API Recommended Practice 752 (API RP 752), Management of Hazards Associated with Locationof Process Plant Permanent Buildings, updated in the pertinent part in 2009, provided additional
guidance to companies operating facilities covered by the OSHA PSM standard “for managing therisk from explosions, fires and toxic material releases to on-site personnel located in new andexisting buildings intended for occupancy [91, p. 1].” API RP 752 offered a systematic process for
siting evaluations of both new and existing buildings [91, p. 5]. API RP 752 excluded storage
facilities, such as the Arkema Low Temperature Warehouses for organic peroxides products,
however, because such warehouses primarily store materials and are only intermittently occupied[91, p. 5].
258. In its book Guidelines for Hazard Evaluation Procedures, CCPS identified the following threeoverlapping aspects of facility siting:•

Facility location with respect to its surroundings;•

Facility layout and spacing of equipment and buildings; and•Personnel protection in occupied buildings [92, p. 288].

259. Although the Guidelines for Hazard Evaluation Procedures book did not exclude the potential
evaluation of flood hazards, it did not offer specific guidance on how companies can evaluate floodrisk [92]. CCPS did describe a conceptual facility hazard analysis where the hazard review team
identified potential equipment damage attributable to flooding by including a specific flood riska29 C.F.R. § 1910.119 and 40 C.F.R. §§ 68.150-68.195.

104

CSB · Investigation Reportquestion to the hypothetical facility in the illustrative analysis, based on its proximity to a river [92,pp. 330-336].
260. The CCPS guidelines noted the importance of severe weather events:
Frequently, causal events initiated outside the fenceline are discussed
almost as an afterthought. Floods, power loss, high winds, earth
movement, and other forces of nature, while unpredictable in timing andforce, can have a more or less predictable impact on the process.
Predictable effects such as these can be addressed and controlled to protect
people, property, and the environment [92, p. 202].
261. In its book Guidelines for Facility Siting and Layout, CCPS noted that many states and local areas
have enacted zoning restrictions designed to minimize potential damage from flooding [93, p. 32].
These regulations might limit a company’s ability to construct a facility in a flood-prone area ormight restrict the type of equipment installed at certain elevations [93, p. 32]. CCPS identified
flood information such as the following that companies should review and consider when selecting
a new site:•

Obtaining flood history information―including dates, total rainfall, and flood depth;•

Identifying whether a flood control organization for the area is in place and who is
responsible for the operation and maintenance of flood control equipment; and•Determining whether any flood models have been developed for the area [93, p. 157].

262. To evaluate facility siting a hazards, Arkema technical PHA team members, including at least one
operator, reviewed a facility siting checklist for “qualitatively identifying types and magnitudes of
releases that impact people in the workplace and in the community … .” This checklist, however,
did not include any prompts or guidewords about flooding or flood risks.
263. Companies might decide that the PHA process is an appropriate venue for evaluating facility flood
risks; however, PHA teams often do not include personnel with expertise in evaluating flood risks.
Civil engineers represent one group of professionals with relatively more flood risk expertise, so
consideration should be given to adding this skill to the team for flood risk identification andevaluation [94].
264. Industry guidance should include evaluations of potential flood risks, and if a PHA team identifies
the potential for a flood risk at its facility, the team should be expanded to include at least one
member with flood risk expertise.
265. In the PSM standard, OSHA defined the following requirements for a PHA team:aArkema defines facility siting as “the spatial relationship between the hazards of the covered process and the location(s) of
humans in the plant, the identification of hazards that may affect adjacent process plant buildings and management of risks
related to those hazards.”

CSB · Investigation Report

105

•

A team with expertise in engineering and process operations;•

At least one employee with experience and knowledge specific to the process being
evaluated; and•One person knowledgeable in the specific PHA methodology being used. a266. Although OSHA does not define specific engineering discipline(s) that should be represented in a
PHA, chemical engineers are most often involved. Although some chemical engineers might beknowledgeable about flood risks, companies might need to provide training to its chemicalengineers or secure outside professional engineering assistance, such as civil engineers or otherprofessionals with relevant flood evaluation experience, to assist with a comprehensive flood risk
assessment.

a

29 C.F.R. § 1910.119(e)(4).

106

CSB · Investigation Report

9. OTHER FLOODING INCIDENTS
267. A number of flooding incidents have impacted industrial facilities over the years. This section
includes a brief discussion of two relevant incidents, the Fukushima nuclear reactor incident and the
San Jacinto pipeline incident. Although the consequences of the Fukushima incident were much
more severe than those of the Crosby incident, industry can still apply the lessons learned from bothincidents to help prevent losses from extreme weather in the future.

9.1.

FUKUSHIMA DAIICHI ACCIDENT REPORT268. The Great East Japan Earthquake struck on March 11, 2011, registering a magnitude of 9.0 andcausing a tsunami that struck the northeastern coast of Japan, where waves reached a height of morethan 30 feet [95, p. 1]. The earthquake and tsunami resulted in more than 15,000 deaths and morethan 6,000 injured victims. Buildings and infrastructure along Japan’s northeastern coast sufferedconsiderable damage [95, p. 1].
269. The earthquake and tsunami resulted in a nuclear incident at the Fukushima Daiichi nuclear power
plant operated by the Tokyo Electric Power Company [95, p. 1]. The incident ranked as the worst
nuclear power plant incident since the Chernobyl disaster in 1986. The release of radionuclides at
the Fukushima power plant forced the evacuation of more than 100,000 people within a radius of 20
kilometers (12.5 miles) [95].
270. As a result of the Fukushima incident, the International Atomic Energy Agency (IAEA) conducted
an investigation with the stated purpose of considering “human, organizational, and technicalfactors, and aims to provide an understanding of what happened and why, so that necessary lessons
learned can be acted upon [95].” The report found weaknesses in the plant design, emergency
preparedness, planning for severe incidents, and response arrangements [95]. The investigation
also found that “there was an assumption that there never [would] be a loss of all electrical power ata nuclear power plant for more than a short period” and that “insufficient provision was made forthe possibility of a nuclear accident occurring at the same time as a major natural disaster [95].”
Despite the major difference in consequences between the Fukushima and Arkema Crosby
incidents, there are similarities in the lessons learned from both incidents.
271. The Great East Japan Earthquake damaged the electric power supply at the Fukushima facility andthe associated tsunami caused substantial damage to the site’s infrastructure. These combined
failures led to the total loss of offsite and onsite electrical power which resulted in the loss of thecooling function at the three operating reactor units as well as at the spent fuel pools [95]. Despite
the efforts of workers at the facility, three reactor cores overheated; the nuclear fuel melted; andthree containment vessels were breached. Moreover, a hydrogen release led to an explosion thatinjured workers and released radionuclides into the environment [95]. Figure 56 shows the waterheight at the Fukushima facility as a result of the tsunami. The water level exceeded the height ofboth the primary electrical equipment (switchgears) and the backup systems (diesel generators).

CSB · Investigation Report107Figure 56. Water Level at the Fukushima Plant. This IAEA figure shows the water level at the
Fukushima plant as a result of the tsunami caused by the Great East Japan Earthquake [95].

272. Like the flooding caused by Hurricane Harvey, the earthquake and tsunami significantly exceeded
the hazard assumptions made when the Fukushima plant was originally designed [95, p. 3]. The
seismic hazard and wave height considered in the original design were evaluated mainly on thebasis of historical weather and seismic data [95, p. 3]. In addition, before the incident, the area wascategorized as having the potential for a magnitude 8 class earthquake, but a magnitude 9
earthquake was deemed not to be credible [95, p. 3].
273. The IAEA report made the following findings, which also could be implemented at hazardous
chemical facilities preparing for extreme weather events:
The assessment of natural hazards needs to be sufficiently conservative.
The consideration of mainly historical data in the establishment of thedesign basis of nuclear power plants is not sufficient to characterize therisks of extreme natural hazards. Even when comprehensive data are
available, due to the relatively short observation periods, large
uncertainties remain in the prediction of natural hazards [95, p. 4].
The assessment of natural hazards needs to consider the potential for theiroccurrence in combination, either simultaneously or sequentially, and their
combined effects on a nuclear power plant. The assessment of natural
hazards also needs to consider their effects on multiple units at a nuclear
power plant [95, p. 4].
274. Like hazardous chemical facilities, nuclear power plants mitigate risks by implementing multiple
independent layers of protection. The Fukushima power plant relied on four layers of protection toprevent the release of radionuclides into the environment. These layers were created to protect

108

CSB · Investigation Reportagainst a wide range of potential hazards, but external hazards such as flooding caused by tsunamis
were not fully addressed [95, p. 5]. As a result, the flooding simultaneously disabled three layers ofprotection, which failed because of a single common cause. The IAEA report concluded:
The common cause of failures of multiple safety systems resulted in plantconditions that were not envisaged in the design. Consequently, the meansof protection intended to provide the fourth level of defence in depth, thatis, prevention of the progression of severe accidents and mitigation of theirconsequences, were not available to restore the reactor cooling and tomaintain the integrity of the containment. The complete loss of power, thelack of information on relevant safety parameters due to the unavailabilityof the necessary instruments, the loss of control devices and theinsufficiency of operating procedure made it impossible to arrest the
progression of the accident and to limit its consequences [95, p. 5].
275. In the 1960s and 1970s, when the Fukushima facility was originally designed and constructed, thenuclear industry practice was to use historical weather and seismic data to estimate external hazards
such as earthquakes and flooding [95, p. 50]. Operators would add a conservative safety factor to
the analysis by assuming that any event would happen at the closest possible location to the facility
and then would increase the maximum recorded event by some level [95, p. 50]. The Fukushimaplant used official sources to obtain a “conservative” estimate for maximum earthquake intensity
and tsunami wave height, but these values were less than those of the actual events on March 11,
2011. For example, the maximum wave height estimate was based on a 1960 earthquake in Chilethat resulted in wave heights around 10 feet above sea level, a third of what Fukushima actuallyexperienced [95, p. 50]. In 2009, the wave heights were reassessed at about 20 feet above sea level,
which prompted the facility to raise the motors on certain pumps [95, p. 51]. This elevation level
still proved insufficient, however, because the facility had not elevated the backup generators
following this reassessment [95, p. 51].

9.2.

SAN JACINTO PIPELINE FLOODING INCIDENT

276. In October 1994, atmospheric moisture from Hurricane Rosa contributed to major flooding of the
San Jacinto River watershed near Houston, Texas [96] and [97]. The San Jacinto watershed is a
few miles to the west of the Arkema Crosby facility and is adjacent to the Cedar Bayou watershed
where the Arkema facility sits [97]. The flooding resulted in ruptures in eight pipelines and damage
to 29 others [98, p. v]. More than 35,000 barrels of petroleum and petroleum products werereleased into the river [98, p. v]. The ignition of hydrocarbons released into the river resulted inburn and inhalation injuries for 547 people [98, p. v]. a (Figure 57).

aVideo showing local news coverage of San Jacinto River fire [222].

CSB · Investigation Report109Figure 57. San Jacinto River Fire, 1994. This local news photo shows the San Jacinto River fire in
October 1994 after pipeline ruptures resulted in the release of petroleum products [99].

277. During one week in October 1994, 15 to 20 inches of rain fell on the San Jacinto River near
Houston as the remnants of Hurricane Rosa stalled over southeast Texas [98, p. 2]. This rainfall
produced flooding that was “an extreme and dangerous event [96].” a The floodwater forced 14,000
people to evacuate their homes and resulted in 20 deaths [98, p. v]. The pipeline spill response
costs exceeded $7 million, and estimated property damage losses were around $16 million [98, p.
v].
278. On October 19, 1994, flooding caused the first pipeline, a liquefied petroleum gas pipeline eight
inches in diameter, to fail [98, p. 4]. By the following day, October 20, 1994, a number of otherpipelines failed, including a 40-inch pipeline and a 36-inch pipeline that transported gasoline [98,pp. 4-6]. On October 20, 1994, the released gasoline ignited, producing five distinct explosions[98, p. 6]. A nine-mile evacuation radius was established around the pipeline releases [98, p. 7].
On October 23, 1994, the emergency response group conducted a controlled burn of the remaining
uncombusted released petroleum products [98, pp. 13-17].
279. The National Transportation Safety Board (NTSB) investigated the incident and released a report in1996 [98]. In its investigation, the NTSB reviewed pipeline failures in the U.S. attributable toflooding over a three-year period (1991–1993) [98, p. 35]. The investigation found that during thistime period, 21 pipelines ruptured during floods, including 13 natural gas pipelines and 3a

The National Transportation Safety Board (NTSB) report details the historical flooding near Houston, showing the area that was
known to flood, and had flooded 17 times between 1907 and 1996 [98, p. 4].

110

CSB · Investigation Reportcontaining “highly volatile liquids” [98, pp. 35-36]. As a result of this investigation, the NTSB
issued nine safety recommendations to prevent recurrence of such an incident [98, p. v].
280. The NTSB investigation report drew 11 conclusions, and at least the following two apply to the
Arkema Crosby flooding incident:
1. The design bases of most pipelines undermined or ruptured during theflood did not include study of the flood plain to identify potential
threats; rather, operators used only general design criteria applicableat the time the pipelines were installed [98, p. 47].
2. Standards for designing pipelines across flood plains are needed todefine the multiple threats posed to pipelines and to address theresearch, study, and future considerations that must be used fordesigning pipelines and periodically reevaluating the integrity of theirdesigns during their operating life [98, p. 47].

CSB · Investigation Report11110. EMERGENCY RESPONSE ACTIVITIES
281. Even before the Arkema Crosby incident began, the emergency response community was fully
occupied with Hurricane Harvey, which prompted the largest disaster response in Texas history[27]. Emergency responders performed more than 120,000 rescues, using 82 aircraft and more than
100 boats [27]. More than three million meals and bottles of water were distributed to those inneed, and over 24,000 displaced residents were housed in hotels [27]. More than 21,000 Federal
staff members were deployed in support of Hurricane Harvey relief, and 53,000 pounds of medical
equipment and supplies were dispatched to Texas and Louisiana [100]. The Federal staff included
more than 6,300 active-duty military personnel who were deployed [100].
282. When Hurricane Harvey reached the Texas coast, a Unified Command was established between the
EPA, TCEQ, U.S. Coast Guard, and Texas General Land Office to oversee all emergency response
activities [101]. The National Guard and Federal Urban Search and Rescue supported this Unified
Command [101]. The Unified Command organized itself into three operational branches in Corpus
Christi, Houston, and Beaumont [101]. In the Houston region, Harris County aided the Unified
Command by providing its emergency response assets, including the Harris County Fire Marshal’s
office and the Harris County Fire Department.
283. The U.S. Army Corps of Engineers assigned more than 150 personnel to engage in flood mitigationand infrastructure recovery tasks throughout the response [100].
284. EPA deployed its Airborne Spectral Photometric Environment Collection Technology (ASPECT)
surveillance aircraft during the incident to monitor for airborne toxic chemicals [101]. ASPECT
testing did not identify any levels of chemicals above baseline concentration when the organic
peroxide refrigerated trailers burned [101]. During the chain of events around the decomposition of
the organic peroxide products in the refrigerated trailers, EPA monitored smoke and air quality,
checked the potential for additional fires in the area, and collected downstream surface water
samples at four locations to test for organic chemicals likely to come from the Crosby facility [101].
Despite the reported releases at the Arkema Crosby facility, including the burning of the nineorganic peroxide trailers, none of these samples detected any organic peroxides or their likely
decomposition products.

112

CSB · Investigation Report11. EVACUATION ZONE
285. In setting up the 1.5-mile evacuation zone, emergency response officials considered several factors,
including staffing requirements to maintain the evacuation perimeter, air quality from the potential
burning of refrigerated trailers temporarily storing organic peroxide products, and potential releasesof sulfur dioxide or isobutylene, the EPA regulated chemicals identified in the Arkema Risk
Management Plan. Arkema stores and uses sulfur dioxide and isobutylene to manufacture organic
peroxides.

11.1. SULFUR DIOXIDE
286. The Arkema Crosby sulfur dioxide storage tank (Figure 58) was located more than 300 feet fromthe isobutylene storage tank and about 400 feet from the nearest refrigerated trailer storing organic
peroxide products. Despite the unlikely nature of a release, emergency response officials modeleda sulfur dioxide release of 16,000 pounds per hour, based on a scenario where a pressure-relief
device on the tank opened and remained stuck in the open position. It should be noted that nosulfur dioxide was released during the incident.

Figure 58. Crosby Sulfur Dioxide Storage Tank. The sulfur dioxide storage tank at the Arkema
Crosby facility was roughly 300 feet from the isobutylene tank and 400 feet from the nearest
refrigerated trailer storing organic peroxide products during the incident. (Source: CSB Photo)

287. The modeling evaluated the potential downwind distance for sulfur dioxide concentrations meeting
the Acute Exposure Guideline Levels (AEGLs), AEGL-3 and AEGL-2. AEGL values aredescribed as follows:•

AEGL-3: Death Possible – the airborne concentration of a substance above which it ispredicted that the general population, including susceptible individuals, could experience
life-threatening health effects or death [102, p. 394].
CSB · Investigation Report

113

•

AEGL-2: Injury Possible – the airborne concentration of a substance above which it ispredicted that the general population, including susceptible individuals, could experience
irreversible or other serious and long-lasting adverse health effects or an impaired capability
to escape [102, p. 394].

288. The models used the AEGL values for a four-hour exposure to sulfur dioxide, 0.75 parts per million(AEGL-2) and 19 parts per million (AEGL-3) [102, p. 397].
289. The modeling results showed that no AEGL-3 or life-threatening concentrations of sulfur dioxide
extended beyond about one mile from the Arkema Crosby facility. Injuries to members of the
public from AEGL-2 concentrations of sulfur dioxide could, however, extend several miles fromthe Arkema site. Because emergency response officials did not consider this scenario as credible,
the evacuation zone was not extended to account for this possibility.

11.2. ISOBUTYLENE
290. The Arkema isobutylene storage tank (Figure 59) was more than 100 feet from the nearest
refrigerated trailer of organic peroxide products. To evaluate the potential isobutylene hazard,
emergency response officials modeled an explosion of the isobutylene storage tank. The modeling
results showed that the predicted blast pressure effects were concentrated within the Arkema
Crosby facility.

114

CSB · Investigation ReportFigure 59. Arkema Crosby Isobutylene Storage Tank. The isobutylene storage tank at the Arkema
Crosby facility was located more than 100 feet from the nearest refrigerated trailer containing
organic peroxide products. (Source: CSB Photo)

11.3. STILL-UNKNOWN POTENTIAL HEALTH EFFECTS FROM THE RELEASE AND
BURNING OF ORGANIC PEROXIDES AT THE ARKEMA FACILITY
291. The CSB is not aware of whether there are long-term health effects that could arise from the type of
exposure first responders and Crosby area residents may have had to either the vapor cloud or thesmoke caused by the decomposition of the various organic peroxides products, or the combustion of
the peroxides packaging materials and trailers. The CSB cannot make a statement regarding thetoxicity or potential health effects of the airborne threat presented by this incident. Some emergency
responders and members of the local community were concerned about potential health effects fromthe vapor cloud emitted by decomposing organic peroxides and from the smoke caused by theburning organic peroxides and combusting refrigerated tractor trailers where Arkema temporarily
stored those products. The CSB has reviewed relevant Safety Data Sheet (SDS) information
provided by Arkema, but no existing SDS covers the unknown quantity and composition ofsubstances in the vapor cloud, as well as the trailers used to contain the organic peroxide products
after they were moved from the Low Temperature Warehouses.
292. As noted previously, the EPA deployed personnel and equipment to this incident to monitor the
impact of any releases on the air and water quality. Through its airborne ASPECT testing andsurface groundwater testing, EPA detected no evidence of organic peroxides. In addition, the EPA
applied its Air Quality Index (AQI) metric and the accompanying methodology, trying to determine
potential health effects that could be experienced by those breathing unhealthy air. For example,
breathing soot particles from the incomplete combustion of burning organic peroxide products andthe refrigerated trailers, or inhaling any associated particulate matter, could cause negative healtheffects.

CSB · Investigation Report115293. AQI is a metric used to represent the health effects that people might experience within a few hours
or days after breathing unhealthy air [103, p. 2]. EPA officials evaluated potential soot particles
that they anticipated after incomplete combustion of the organic peroxide products and therefrigerated trailers; such particle pollution or particulate matter is one of the established AQI
pollutants. a The EPA brochure Air Quality Index: A Guide to Air Quality and Your Health notesthat “people with heart or lung disease, older adults, b and children are considered sensitive andtherefore at greater risk [103, p. 3].” To evaluate possibly unhealthy air conditions from the Crosby
incident, these same officials developed models using EPA’s AQI levels of health concern forunhealthy, very unhealthy, and hazardous air. The EPA explanations for these air quality categories
are as follows:•

Unhealthy: Everyone might begin to experience health effects when AQI values fall
between 151 and 200. Members of sensitive groups might experience more serious healtheffects.

•

Very Unhealthy: AQI values between 201 and 300 trigger a health alert. Everyone mightexperience more serious health effects.

•

Hazardous: AQI values exceeding 300 trigger a health warning about emergency
conditions. The entire population is even more likely to be affected by serious health effects[103, p. 3].

294. EPA officials also attempted to develop models incorporating the AQI, by using the three tiered
categories that would demonstrate increasing potential health threats as AQI scores rose. But
because the models of anticipated dispersion for the Arkema Crosby incident did not reflect thenature of actual dispersions that occurred, among other practical difficulties, any attempts by EPA
to analyze ongoing or long-term health threats based on the tiered modeling using AQI remains
inconclusive. It is impossible for the CSB to draw any meaningful conclusions on the topic, in theabsence of additional data based on relevant evidence in the form of air emissions from the Crosby
incident, which began to disappear within a matter of hours or days as vapor and smoke dissipatedfollowing the release. As a result, this report does not seek to analyze the health effects stemmingfrom the decomposition of the organic peroxides at the Arkema Crosby facility beyond noting theapparent short-term health effects suffered by those people who reported for medical treatment
following their exposure as an important aspect of the incident.

11.4. STAFFING RESOURCES
295. On the basis of the results from evaluating the sulfur dioxide, isobutylene, and air quality scenarios,
emergency response officials identified a need for a 1-mile evacuation perimeter. Emergency
response personnel represented a key factor, however, because of the high demand for emergencyab

The other three Air Quality Index pollutants are ground-level ozone, carbon monoxide, and sulfur dioxide [103, p. 2].
“Due to the normal aging process, older adults may experience increased health risks from exposure to unhealthy air. Studies
indicate that some people become more sensitive in their mid-60s. However, the risk of heart attacks, and thus the risk fromparticle pollution, may begin as early as the mid-40s for men and mid-50s for women [103, p. 3].”116

CSB · Investigation Reportresponders to support Hurricane Harvey flooding relief throughout Harris County. When assessing
staffing requirements to support a 1-mile perimeter, emergency response officials found that thelayout of local roads required fewer personnel for a 1.5-mile evacuation perimeter. Because theextra half-mile not only provided a larger and safer perimeter, but also required fewer emergency
responder resources, officials selected and established a 1.5-mile public evacuation zone.

11.5. KEEPING HIGHWAY 90 OPEN
296. Even after the evacuation zone was enforced, Highway 90, which ran through the middle of theevacuation zone and near the Crosby facility, was left open to traffic. The Unified Command madethis decision, in part, because Highway 90 was the only remaining major throughway fortransporting personnel and equipment from the Houston area to the Beaumont region, where
Hurricane Harvey was causing severe flooding. This situation posed a difficult decision for all
emergency responders and the Unified Command. On one hand, the Unified Command had toconsider the potential safety threat posed by organic peroxides which were no longer being
adequately cooled and had to be decomposing at an increasing rate. On the other hand, Highway 90
served as a vital transportation corridor as Hurricane Harvey tracked east and emergency
responders and other related resources needed to move with the storm. The emergency responders
planned to monitor the situation at the Crosby facility and to shut down Highway 90 at the first signof any fire in, or chemical release from, the refrigerated trailers.
297. Starting on Wednesday, August 30, 2017, Arkema provided telemetry data to the Unified
Command showing that the air temperatures in six of the refrigerated trailers loaded with organic
peroxide products were increasing and air temperatures inside three of these trailers were above theestimated SADTs of the organic peroxide products. The first refrigerated trailer to combust,
however, did not have the capability to generate telemetry data and emergency responders could notaccurately predict the time when the organic peroxide products in that trailer would begin todecompose. Moreover, although the ride-out crew gave its best approximation of the organic
peroxide products in each refrigerated trailer, because of the hectic nature of the process for loading
the trailers, the crew could not be completely sure that its list was accurate. Consequently, when
the organic peroxide products in the refrigerated trailer (the first one to burn) reached a sufficiently
high temperature to begin the rapid decomposition and combustion process, Highway 90 was still
open. a298. At about 11:50 pm on Wednesday, August 30, 2017, the organic peroxide products in the firstrefrigerated trailer were likely decomposing when two officers drove through a white smoke cloudcoming from the Arkema Crosby facility. The emergency responders shut down Highway 90 after
the officers reported the white smoke; however, emergency responders soon reopened it based onlack of visual confirmation of decomposition at the Crosby facility, and based on the telemetry data
indicating that no decomposition should be occurring. When the white smoke cloud could not be
visually confirmed at the Arkema facility, the emergency responders concluded that the cloud thea

It is not possible to determine the exact composition of chemicals people were exposed to from the release, because multiple
organic peroxide products were stored in the refrigerated trailers and were in varying degrees of decomposition with limited
oxygen when they combusted.

CSB · Investigation Report117officer drove through had been a “low lying weather cloud” (most likely fog), based on the reported
description of a white cloud. Because the initial organic peroxide decomposition was notconfirmed, the emergency responders reopened Highway 90. Although an admittedly difficult
decision, the choice to reopen Highway 90 allowed more emergency responders and private
individuals alike to be potentially exposed to the chemical cloud. Only after the emergency
responders later confirmed the organic peroxide decomposition did they shut down all lanes ofHighway 90.
299. This incident demonstrates the difficulty of weighing options during an emergency response. The
Arkema Crosby incident was occurring within the context of the larger emergency precipitated by
Hurricane Harvey. The needs of officials who were strictly enforcing an evacuation zone conflictedwith the needs of officials providing support for the response to Hurricane Harvey. Emergency
officials understandably kept Highway 90 open initially. But once a report came in that thesituation at the Crosby facility became less stable and that decomposition might be occurring,
emergency response officials should have closed Highway 90 and established alternative routes. In
an emergency, data are frequently incomplete and can even be contradictory, so emergency
responders must tend towards being as conservative as might be prudent so that they can err on theside of caution and protect both themselves and the public.

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CSB · Investigation Report12. FREQUENCY AND COST OF FLOODING NATURAL DISASTERS
300. The reliability of flood-frequency estimates for large recurrence intervals (such as 100-year or 500year floods) is uncertain [54, p. 2].
301. The European Commission Joint Research Centre published a report in 2004 that estimated thedollar losses from natural disasters in the United States had increased from $4.5 billion annually in1970 to $6 to 10 billion annually in 1999 (all in 1970 dollars) [104, p. 2]. a As the rate of natural
disasters increases, the frequency and cost of incidents at chemical facilities affected by suchnatural disasters might also rise unless appropriate actions are taken to strengthen the resilience ofthe facilities.
302. In recent years, flooding from extreme rainfall events has escalated, and some EPA climate experts
project that this trend will continue [105] and [106], resulting in an increased flood risk in many
parts of the United States [106]. Future projections show Texas leading the nation in potential
flood damage (Figure 60) [106].

Figure 60. Future Flood Damages Attributable to Unmitigated Climate Change [106]. b, c This
projection used 2014 U.S. dollars as the basis for the future damage estimates.

303. A 2017 study by Swiss Re, an international insurer, found that worldwide insured losses fromdisasters d had fueled a surge in insurance claims in 2016 because of an increase in natural disasters
including earthquakes, storms, floods and wildfires [107]. The report found that in 2016, 42
percent of insurance losses were attributable to natural disasters; in addition, in contrast to thedecrease in human-induced disasters, natural disasters continued to increase (Figure 61) and (Figure62) [108]. North America experienced the highest insured losses from disaster events in 2016, witha

In 2017 dollars, the losses in 1970 were $28.4 billion, and by 1999, they had increased to $63.1 billion [223].
“For more information, visit EPA’s Climate Change in the United States: Benefits of Global Action [182].” (Hyperlink added.)c“Climate change refers to any significant change in the measures of climate lasting for an extended period of time. In otherwords, climate change includes major changes in temperature, precipitation, or wind patterns, among other effects, that occur
over several decades or longer [229].” (Hyperlink added.)d
The report characterized a disaster (catastrophe) as an event producing insured losses that exceed $109 million or resulting in atleast 20 deaths, 50 injured people, or 2,000 homeless victims [108, p. 2].
b

CSB · Investigation Report119most of the losses stemming from hurricanes, hailstorms, thunderstorms, and severe flood events[108].

Figure 61. Swiss Re Study on Insured Losses. International insurer Swiss Re studied insurance
losses attributable to disasters from 1970 to 2016 [108, p. 2].

Figure 62. Insured Losses from Catastrophes, 1970 through 2016. Swiss Re studied the value of
insurance losses from disasters from 1970 through 2016 (in billions of U.S. dollars and 2016 prices[108, p. 4].

304. The 2016 Swiss Re report also identified flooding as an underinsured risk in the United States[108]. This conclusion indicates that people and industry might not view the flooding risk as
seriously as they should. The report stated that the United States “remains highly vulnerable toflood risk [108, p. 14].” The report specifically mentions the Houston metropolitan area as built on
floodplains and prone to flooding during heavy rains, noting that “the multi-billion dollar losses that
Houston suffered after two separate inland flood events in 2016 and 2015 are not entirely
inexplicable [108, p. 15].”120

CSB · Investigation Report305. Swiss Re proposes that the underinsuring of flooding in America is attributable to a “shortcomingof loss experience from a selection of individual events” that “do not necessarily reveal the true
extent of underlying risk [108, p. 16].” Essentially, Swiss Re concluded that people are relying on
their own memories of flooding to understand the risk, which is an insufficient basis forrecognizing the full extent of the risk. This attitude was prevalent at the Arkema Crosby facility as
well, with flooding expectations based on employee memories of previous rain events and how they
had affected the facility. Compared to the assessment of risk based on scenarios that occur overhundreds of years, reliance on personal experience, which has a limit of several decades, is an
unreliable method of risk evaluation. High-consequence but low-frequency events―such as
flooding that occurs only once every several decades―might not be fully captured. Even with thisrealistic outlook, Swiss Re expected that flooding insurance claims in the United States would bearound $15 billion annually. A few months after Swiss Re published its report, Hurricane Harvey
caused more than $20 billion in flood damage.

CSB · Investigation Report12113. NATECH RISK ASSESSMENT AND MANAGEMENT
306. Because of a number of chemical releases that occurred in the wake of extreme weather events
around the world (starting with a Turkish earthquake in 1999 and floods across Europe in 2002), theEuropean Commission, in conjunction with other groups such as the Disaster Prevention ResearchInstitute in Kyoto, Japan, began to analyze how these incidents can be avoided in the future [104, p.
1]. This group found that little information was available on the risk of industrial incidents during
extreme weather events (a type of natech a) [104, p. 1].
307. The latest book by the European Commission Joint Research Centre (EU-JRC) on industrial
incidents caused by extreme weather notes the following:
The past years set a record in the number of natural disasters accompanied
by unprecedented damage to industrial facilities and other infrastructures.
In addition to the Japan twin disasters in 2011 [earthquake and tsunami],
recent major examples include Hurricane Sandy in 2012 that caused
multiple hydrocarbon spills and releases of raw sewage, the damage toindustrial parks during the Thai floods in 2011, or Hurricanes Katrina andRita in 2005 that wreaked havoc on the offshore oil and gas infrastructurein the Gulf of Mexico. These events clearly demonstrated the potential fornatural hazards to trigger fires, explosions, and toxic or radioactive
releases at hazardous installations and other infrastructures that process,store, or transport dangerous substances. These technological “secondary
effects” caused by natural hazards are also called “Natech” accidents.
They are a recurring but often overlooked feature in many natural-disastersituations and have repeatedly had significant and long-term social,environmental, and economic impacts [85, p. 1].
308. Natech hazards increase the burden on a population already coping with extreme weather eventsand can result in multiple and simultaneous releases of hazardous chemicals over large areas [85, p.
1]. The EU-JRC points out that the risk from extreme weather is difficult to ascertain because thismultidisciplinary topic cuts across traditional professional boundaries [85, p. 3]. For example, theflooding event at the Crosby facility is largely a civil engineering issue, but because the floodwater
caused a loss of cooling for organic peroxide products, the civil engineering discipline intersectedwith the chemical and electrical engineering disciplines. Moreover, the risk from extreme weather
is still considered an emerging risk and thus has received more attention in reaction to recent
incidents [85, p. 3]. Further complicating an appropriate response is the conviction that existing
protection measures and layers of protection to prevent “conventional” industrial incidents will also
defend against extreme weather incidents [85, p. 3].
309. The EU-JRC natech report also notes that extreme weather scenario planning must assume scarceemergency response personnel and associated resources because the emergency responders likely
would be dealing with many effects of the extreme weather and because the releases of hazardousaA natech is defined as a technological disaster triggered by any type of natural disaster [104, p. 1].

122

CSB · Investigation Reportchemicals could endanger the emergency responders themselves as well as the completion of theirimportant tasks [85, p. 4]. Extreme weather, especially flooding, can limit access to or from afacility that is experiencing an incident. If roads are not accessible and passable, emergency
responders might not be able to reach a facility, and community members might be unable toevacuate.
310. Risk mitigation planning for extreme weather pays dividends [85, p. 35]. Unsurprisingly, the EUJRC reports that companies fare better during extreme weather events if they have implemented
risk reduction measures and if they design specifically for extreme weather [85, p. 35]. The reportstates that industry and authorities do not generally appreciate the likelihood of significant effects
from extreme weather. The EU-JRC also identified a lack of guidance on how to address extreme
weather risks [85, p. 35].
311. The EU-JRC found that the largest problem area for companies was not properly preparing fornatural hazards rather than experiencing the failure of safety systems [85, p. 35]. The reportconcluded that chemical facilities often use generic design criteria as a basis for safeguards and do
not take into account the likelihood of extreme weather at each individual location [85, p. 35].
312. Flooding at a facility can lead to a variety of modes of operational failure and chemical release by avariety of methods. For example, floodwater can lift vessels, especially atmospheric storage tanks,
from their footings, leading to a release of their contents. Floating vessels not only can release theircontents, which can lead to a more serious incident, but also can impact other stable or floating
vessels. Water can increase drag forces and cause piping connections to fail [85, p. 40]. Water can
intrude into electrical equipment, as it did at the Arkema Crosby facility, causing power failure andindirectly triggering an incident. Flooding frequently affects large areas and can deposit hazardous
chemicals over a wide region if they are released [85, p. 42]. This multilayered risk threatens boththe communities around the facilities and the surrounding environment.

CSB · Investigation Report12314. HURRICANE HARVEY OTHER INDUSTRIAL RELEASES
313. As part of the response to Hurricane Harvey, 263 EPA personnel supported the relief efforts [101].
A total of 41 Superfund sites were located in the area affected by Hurricane Harvey [101]. The
EPA reported on September 2, 2017, that of those 41 Superfund sites, 13 were flooded orexperienced possible damage attributable to the storm [109]. Of those 13 sites, 11 were
inaccessible during the hurricane because of flooding, so EPA personnel could not conduct
sampling until after the floodwater had receded [109]. Once the EPA conducted the sampling, theagency determined that the contamination at all but one of the Superfund sites was consistent withthe existing contamination before the hurricane [110].
314. The San Jacinto River Waste Pits Superfund site contains toxic dioxins [111]. The site is located inHarris County and consists of impoundments that were constructed in the 1960’s for the disposal of
paper mill wastes [112]. The impoundments are about 34 acres in size and are on the west bank of
the San Jacinto River. EPA conducted testing after the hurricane and found that a protective cap(put in place to prevent the release of contaminants) had been damaged during the flooding and that
underlying waste material was exposed [113]. The sample showed dioxin levels higher than 70,000
nanograms per kilogram although EPA’s recommended cleanup level for the site is 30 nanograms
per kilogram [113]. Subsequent analysis determined that the flooding had eroded the river bottom
under the protective cap by as much as 12 feet [114].
315. During and after Hurricane Harvey, EPA performed air monitoring tests near the refineries insoutheast Houston but did not identify any toxic chemicals that exceeded the normal atmosphericlevels [101]. A light crude oil storage tank at the Valero Houston Refinery, however, failed as aresult of Hurricane Harvey, releasing benzene and other organic compounds [101]. The tank failed
when floodwater lifted the tank from its foundation and the walls separated from the bottom of thetank.
316. The U.S. Coast Guard operates the National Response Center which is the designated Federal pointof contact for reporting all oil, chemical, radiological, biological, and etiological discharges into theenvironment in the United States [115]. When an industrial facility has a chemical release into theenvironment, it is required to alert the National Response Center and to give an account of therelease. a317. Based on National Response Center data during Hurricane Harvey, 102 reported incidents
involving releases to the environment from industrial facilities were in some way caused by thehurricane [116]. Of those reported incidents, 44 releases were done in a “controlled” manner
through the facility flare and were completed during shutdown operations before the arrival of thehurricane and during startup activities after the hurricane had passed [116]. The U.S. Departmentof Energy estimated that immediately before Hurricane Harvey made landfall, 24.5 percent of thecountry’s oil production, 25.9 percent of the natural gas production in the Gulf of Mexico, and 43
percent of the Gulf Coast petroleum refining capacity [117] (12 percent of the U.S. refininga

40 C.F.R. § 302.6

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CSB · Investigation Reportcapacity) were shut-in as a precaution [118]. Large storage tanks accounted for the biggest releases
to the environment because of flooding from Hurricane Harvey [116].
318. For example, the Galena Park, Texas release occurred at a Magellan Midstream Partners, L.P.
facility. Shortly after midnight, September 1, 2017, Magellan alerted the National Response Center
that its Galena Park facility had released an unknown quantity of a “gasoline type product” becauseof floodwater at the facility [116]. In an update 12 hours later, Magellan reported that it had
released 1,000 barrels (42,000 gallons) of gasoline because of flooding [116]. Then, two days later,
Magellan reported that the release had reached a local waterway [116]. On September 5, 2017, fourdays after the release, the company increased the estimated quantity released to 10,988 barrels(about 461,000 gallons) of gasoline [116].
319. The Magellan Midstream Galena Park terminal has the capability to store 7.2 million barrels of
crude oil in above-ground storage tanks [119]. The terminal serves Houston and Texas City
refineries, as well as other terminals and pipelines in the area [120]. Two storage tanks failed
because of high floodwater level, releasing their contents during Hurricane Harvey [121]. The
facility took action to recover the spilled material, capturing approximately 20 percent of the spilled
gasoline, with the rest likely soaking into the ground or evaporating [121].

CSB · Investigation Report12515. RECOMMENDATIONS
Pursuant to its authority under 42 U.S.C. §7412(r)(6)(C)(i) and (ii), and in the interest of promoting
safer operations in the U.S. chemical industry, and protecting workers and communities from future
accidents, the CSB makes the following safety recommendations:15.1. REITERATED RECOMMENDATIONS FROM REACTIVES STUDY TO THE
ENVIRONMENTAL PROTECTION AGENCY
2001-1-H-R3 a
Revise the Accidental Release Prevention Requirements, 40 CFR 68 [Risk Management Plan], toexplicitly cover catastrophic reactive hazards that have the potential to seriously impact the public,
including those hazards resulting from self-reactive chemicals and combinations of chemicals andprocess-specific conditions. Take into account the recommendations of this report [Improving
Reactive Hazard Management] to OSHA on reactive hazard coverage. Seek congressional
authority if necessary to amend the regulation.

15.2. ARKEMA CROSBY FACILITY

Reduce flood risk to as low as reasonably practicable (ALARP). Ensure that any safeguards forflooding meet independent layer of protection requirements.

15.3. ARKEMA INC.

Within 18 months, develop a policy requiring that Arkema and its subsidiaries that manufactureorganic peroxides or that have processes which involve more than the threshold quantities of highly
hazardous chemicals (HHC) b periodically (corresponding with PHA cycle), analyze such facilities
to determine whether they are at risk for extreme weather events such as hurricanes or floods.

Establish corporate requirements for its facilities that manufacture organic peroxides or that haveprocesses which involve more than the threshold quantities of highly hazardous chemicals (HHC) ca

The current status of 2001-1-H-R3 is Open – Unacceptable Response [88]. See Recommendations Status Change Summary for
additional detail and a summary of EPA’s response to this CSB recommendation.
b
29 C.F.R. § 1910.119 Appendix Ac
29 C.F.R. § 1910.119 Appendix A

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to ensure that critical safeguards, such as backup power, function as intended during extreme
weather events, including hurricanes or floods.

15.4. CCPS

Develop broad and comprehensive guidance to help companies assess their U.S. facility risk fromall types of potential extreme weather events. Guidance should address the issues identified in thisreport and cover actions required to prepare for extreme weather, resiliency and protection ofphysical infrastructure and personnel during extreme weather, as well as recovery operations
following an extreme weather event, where appropriate. Include guidance for each of thefollowing:•

Addressing common mode failures of critical safeguards or equipment that could be causedby extreme weather events, including but not limited to flooding. For flooding scenarios,
sufficient independent layers of protection should be available if floodwater heights reachthe facility.

•

Evaluating facility susceptibility to potential extreme weather events. Relevant safety
information such as flood maps should be incorporated as process safety information.

•

Involving relevant professional disciplines, including engineering disciplines, to help
ensure risk assessments and process hazard analyses are as robust as practicable for any
given facility.

15.5. HARRIS COUNTY

Update your emergency operations training using lessons learned from the Arkema incident to help
ensure that personnel enforcing evacuation perimeters are not harmed by exposure to hazardous
chemical releases. Update existing protocols and revise training curricula to include the use ofanalytical tools, air monitoring, and personal protective equipment, to provide appropriate
protection when emergency equipment or personnel need to be moved through an evacuation zone
during a hazardous materials release. Include a process for periodic refresher training.

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USEPA, "General RMP Guidance," April 2004. [Online]. Available: https://www.epa.gov/sites/production/files/201311/documents/chap-06-final.pdf. [Accessed 18 4 2018].

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CSB · Investigation ReportAPPENDIX A: CAUSAL ANALYSISCSB · Investigation Report143

APPENDIX B: ADDITIONAL ORGANIC PEROXIDE INFORMATION
320. Table 6 provides information about the organic peroxides involved in the Arkema Crosby incident
including product trade name, organic peroxide family, maximum storage temperature, selfaccelerating decomposition temperature, and the hazard category (Type) for each product.
Table 6. Refrigerated Organic Peroxide Inventory and Properties. Organic peroxide properties are
excerpted from the Safety Data Sheets (SDS) [122]. a Luperox™ is a trade name that Arkema uses
to market its organic peroxide products.

321. DOT regulations establish seven organic peroxide categories or “types” based on their hazard level,
which is a function of both the properties of the organic peroxides and how the chemicals arepackaged―including the design, style, and size of the container. b Organic peroxides are identified
as Type A through Type G, with Type A representing the greatest hazard and Type G being theleast hazardous. c As shown in Table 6, the organic peroxides involved in the Arkema Crosby
incident are Type C and Type D. These organic peroxides are hazardous, but not the mosthazardous. Although an explosion of Type C or Type D organic peroxides is possible, in their final
product packaging a fire is the more probable hazard in a potential heating scenario, such as
prolonged loss of refrigeration [19]. daNote that there are temperature discrepancies between individual product Safety Data Sheets and the Arkema Organic Peroxides– Their Safe Handling and Use safety guidance document.
b
49 C.F.R. § 173.128 (b) (2004).
c
49 C.F.R. § 173.128 (b) (2004).
d
Safety Data Sheets for organic peroxide Types C through Type F use a flame pictogram and hazard statement that “heating may
cause fire.” Type A and Type B organic peroxides have potential explosion hazards [19].

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CSB · Investigation Report322. Additional information on Arkema’s refrigerated organic peroxides, including National Fire
Protection Association (NFPA) 432, Code for the Storage of Organic Peroxide Formulations,storage classes, is available on the company’s website [11]. In 2007, Arkema published Organic
Peroxides – Their Safe Handling and Use [11]. This safety guidance indicates that the refrigeratedorganic peroxide products involved in the Crosby incident included Class I, II, and III organic
peroxides [11, pp. 6-7]. In developing this guidance document, Arkema used the 1997 edition of
NFPA 432, which defines organic peroxides based on their potential hazard as follows:•

Class I – describes “those formulations that are capable of deflagration but not detonation;” a•Class II – describes “those formulations that burn very rapidly and that present a severereactivity hazard;” and•Class III – describes “those formulations that burn rapidly and that present a moderate
reactivity hazard [123].” b

323. Arkema safety guidance emphasizes the importance of keeping organic peroxides below theirrequired storage temperatures shown in Table 6 [11, pp. 4-5]. c Of the organic peroxides involved in
the Crosby incident, Luperox™ 221 required the lowest storage temperature, minus (-) nine degrees
Fahrenheit (°F) [124]. d Luperox™ 221 is also a Class I organic peroxide, meaning it can deflagrate[11, pp. 6-7]. Although Luperox™ 221 represented the smallest inventory (less than 3,000 pounds)
at Crosby, it still posed an elevated risk given its low SADT of 23 °F [124] and its status as the only
product onsite categorized under this higher risk type.

a

Deflagrations and detonations are types of explosions. Detonations typically create higher pressure and result in more damage
than deflagrations.
b
The definitions provided in the 2002 version of NFPA 432 are the same as those in the 1997 version. NFPA 432 waswithdrawn in 2009 and incorporated into NFPA 400, Hazardous Materials Code [168, p. 1].
cNote that there are temperature discrepancies between this safety guidance document and the individual product Safety Data
Sheets.
d
The Arkema Crosby facility does not manufacture Luperox™ 221, but it is among the organic peroxides manufactured in
Geneseo, New York and shipped to the Crosby facility for temporary storage until sold to customers.

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APPENDIX C: LOSS OF REFRIGERATION RISK ASSESSMENT
324. Arkema completed its most recent process hazard analysis (PHA) for organic peroxide storage at
the Crosby facility in November 2013. The PHA team performing the analysis consisted of amanager who served as the review leader, a safety engineer, a process engineer, an operator fromthe production facility, and an operator from the shipping department with experience working in
the organic peroxide cold storage buildings. The PHA used a Structured What-If methodology.
325. To evaluate risk, companies often use a risk matrix. Figure 63 shows an example of a generic risk
matrix. a Using the Arkema risk matrix, the company’s PHA team evaluated the risk of each hazard
for the following three cases:•

Risk with none of the existing safeguards available (potential);•

Risk with the existing available safeguards (current); and•Risk with existing and proposed safeguards (final).

Figure 63. Generic Risk Matrix. This is a generic risk matrix shown to provide an example that acompany could use to evaluate risk as a function of the frequency and the severity of a potential
hazard. Similar to the Arkema risk matrix, this risk matrix uses three risk levels – tolerable (green),
evaluate options (yellow), and intolerable (red). b

326. For the review of the Low Temperature Warehouses, the following three potential scenarios that
could result in elevated temperature were evaluated:aThis example risk matrix is generally based on an example provided in Layer of Protection Analysis: Simplified Process Risk
Assessment [126, p. 23].
bThis example risk matrix is generally based on an example provided in Layer of Protection Analysis: Simplified Process Risk
Assessment [126, p. 23].

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CSB · Investigation Report•Loss of refrigeration because of a compressor failure;•

Loss of refrigeration because of a refrigerant leak; and•Loss of power.

327. The Arkema PHA did not document whether the team considered flooding as a scenario. a At thetime the Low Temperature Warehouse PHA was performed, corporate PHA requirements did not
mandate that all PHA teams consider flooding scenarios. In 2014, Arkema modified its corporate
PHA policy to require its PHA teams to identify and evaluate natural hazards such as flooding.
328. For a scenario based on loss of power, the Low Temperature Warehouse PHA documented both abusiness consequence and a safety consequence. For a scenario of power loss that results in loss ofthe cooling capability, the PHA team documented the safety consequence as “decomposition of
product with potential fire,” and the effect as “possible personnel injury.” The team further
documented that such an electrical outage would need to last more than four hours before building
temperatures reach the SADT.
329. Following the company’s process, the PHA team first evaluated the risk of this potential loss of
power consequence without any safeguards. The team assigned a frequency level of six (frequent)for this consequence. The frequency of a scenario is determined by using existing Arkema
corporate databases, vendor data, and plant experience. Arkema defined frequent as an “[e]vent
that may happen several times over 10 years of life cycle of an installation.” The team selected aseverity level of three (extensive).
330. Arkema subdivides severity levels into four additional categories:•

Safety – Onsite;•

Safety – Offsite;•

Environmental; and•Financial (dollars or euros).

331. The PHA did not detail the factors that drove the choice of severity level three (extensive). Per the
Arkema PHA policy, a severity level three consequence equated to “Exposure / injury withirreversible effects” or a “public shelter in place” as an offsite impact to members of the public.
332. As shown in Figure 64, mapping this combination of frequency (six) and severity (three) on thegeneric risk matrix, results in an intolerable risk. Although not shown because of confidential
business information concerns, the results using the Arkema risk matrix are similar.

aFlooding is not discussed in the PHA report.

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Figure 64. Example Risk Assessment for Loss of Power to Low Temperature Warehouses With No
Risk Reduction Credit. This example risk assessment approximates Arkema’s potential risk ofpower loss to the Low Temperature Warehouses, without taking any risk reduction credit forsafeguards.

333. Arkema requires that a layer of protection analysis (LOPA) be performed for all scenarios that fallin the red (intolerable risk) boxes in Figure 64 as well as for higher level severity yellow (evaluate
options) boxes. A LOPA is a semi-quantitative method used to analyze and assess risk. Using a
LOPA, the PHA team looks at the safeguards already in place and determines how effective such
safeguards will be in mitigating risk. Depending on the complexity of the scenario, the LOPA
might be conducted by the PHA team or by another team at a different time.
334. The PHA team next identifies the existing safeguards and assigns to each a value for risk reduction
credit. Safeguards identified by the PHA team for the power loss scenarios in the Low Temperature
Warehouse PHA included the following:•

Emergency generators that provide electricity to all Low Temperature Warehouses;•

Liquid nitrogen supply for alternative cooling; and•Manual temperature checks conducted every two hours and the capability to relocate theorganic peroxides from an affected Low Temperature Warehouse to another refrigerated
building or a portable refrigerated trailer.

335. The PHA team assigned two levels of risk reduction for the emergency generators, one for theliquid nitrogen system, and one for the capability to relocate the organic peroxide inventory. In all,the PHA team assigned four levels of risk reduction to these existing safeguards.
336. As shown in Figure 65, by taking four risk reduction credits for the existing safeguards the risk
decreased from an unacceptable or intolerable risk to a tolerable risk. A tolerable risk represented

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an acceptable long-term level of risk for Arkema, so the PHA team did not make any further risk
reduction recommendations.

Figure 65. Example Risk Assessment for Loss of Power to Low Temperature Warehouses with Risk
Reduction Credit. This example risk assessment approximates Arkema’s potential risk of power loss
to the Low Temperature Warehouses with four levels of risk reduction credit for the company’s
existing safeguards.

HARVEY FLOODING – SIMULATED RISK ASSESSMENT
337. Using hindsight knowledge of the Hurricane Harvey organic peroxide decomposition incidents, aswell as Arkema’s corporate requirements for performing a PHA, a simulated risk assessment of thesafeguards in place for Harvey-level flooding can be conducted. This simulated risk assessment isintended to demonstrate the potential of such an extreme weather event at a chemical facility.
338. A rainfall event far exceeding the 500-year flood elevation can be evaluated as a frequency level offour (possible) or three (rare). Under the Arkema PHA policy, a “possible” frequency event is
expected to occur between 1-in-100 to 1-in-1,000 years, but the lowest frequency available forfloodplains is the 500-year elevation, which Harvey exceeded by over two feet. In addition, NOAA
rainfall estimates show the rainfall during Harvey had less than a 1-in-1,000 year likelihood of
occurring, [125] which would be a “rare” frequency event in the Arkema PHA policy. Using thisinformation, a “rare” frequency is assumed for Harvey-level of flooding.
339. Using Arkema’s more detailed severity level guidelines, severity level four (very extensive), is anappropriate severity level for the Hurricane Harvey organic peroxide decompositions, which caused
evacuations. Arkema guidelines for severity level specifically identify an event that results inpublic evacuation as severity level four (very extensive).
340. Figure 66 shows an estimation of Arkema’s risk for the Hurricane Harvey rainfall event. The
combination of frequency of three (rare) for power loss due to flooding, and a severity level four

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(very extensive) consequence due to public evacuation, results in a risk level of two (evaluate
options) without applying any safeguards.

Figure 66. Example Risk Assessment Approximating Arkema’s Potential Risk of Power Loss to the
Low Temperature Warehouses Because of Hurricane Harvey Flooding. No safeguards wereavailable because the flooding that caused the power loss in the Low Temperature Warehouses
also disabled each of the company’s backup systems.

341. Arkema thought that the following safeguards would be available in a scenario where electrical
power was lost:•

Emergency generators to provide backup power;•

Liquid nitrogen to provide emergency refrigeration to the Low Temperature Warehouses;
and•Backup refrigerated trailers to serve as a redundant cold storage location.

342. The Arkema PHA includes a LOPA, a well-recognized hazard analysis method that strives todetermine whether the layers of protection are sufficient to protect against a particular hazard or
accident scenario. In its book Layer of Protection Analysis: Simplified Process Risk Assessment,
CCPS explains, “Layer of protection analysis (LOPA) is a semi-quantitative tool for analyzing andassessing risk [126, p. 1].” a343. In a Harvey-level flooding (significantly exceeding 500-year flood elevation) scenario, with loss ofelectrical power due to flooding, Arkema had insufficient safeguards to reduce the risk. Thea

CCPS defines semi-quantitative as “Risk analysis methodology that includes some degree of quantification of consequence,
likelihood, and/or risk level [178].” The CCPS quote was modified by changing semiquantitative to semi-quantitative.

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CSB · Investigation Reportflooding that caused the facility to lose electrical power also provided a common failure mode of
the safeguards Arkema considered protection layers, including:•

Emergency generators flooded and were not available;•

Liquid nitrogen piping flooded and was not available; and•Refrigerated trailers diesel fuel tanks flooded and were not available.

344. In a LOPA, risk reduction credit is only available for special safeguards that meet establishedcriteria [126, p. 80]. CCPS calls these special safeguards “independent protection layers” or IPLs[126]. To qualify as an independent protection layer, CCPS requires that a device, system, or
action (various types of safeguards) must be:
1. Effective in preventing the consequence when it functions as designed;
2. Independent of the initiating event and the components of any other independent
protection layer already claimed for the same scenario; and3. Auditable – the assumed effectiveness in terms of consequence prevention andprobability of failure on demand must be capable of validation in some manner, such as
by documentation, review, testing, etc. [126, p. 80].
345. In a LOPA, all independent protection layers are safeguards, but not all safeguards are independent
protection layers [126, p. 76].
346. Among the established CCPS requirements, a safeguard must be independent of the initiating eventto serve as an independent protection layer and provide LOPA risk reduction credit [126, p. 80].
The same floodwater that caused the facility to lose electrical power also compromised theemergency generators, liquid nitrogen system, and refrigerated trailers. Ultimately, none of the
Arkema safeguards met the CCPS independent protection layer requirements during Harvey-level
flooding. With insufficient independent protection layers to reduce this risk, the company
unknowingly had a level two (evaluate options) risk, not identified by its PHA. For this simulated
example, Arkema corporate PHA policy would require that LOPA be applied to consider further
risk reduction to “as low as reasonably practicable.”
347. The Arkema manual detailing how to perform a layer of protection analysis describes an initiating
event as “the first event in a sequence of events that leads to the undesirable consequences.”
Among other possibilities, the Arkema layer of protection analysis manual identifies, among otherpossibilities, natural phenomena including floods, hurricanes, and earthquakes as potential initiating
events.
348. Arkema’s internal guidance on layers of protection does not allow safeguards to be considered as
independent protection layers if the initiating event can prevent the safeguard from performing its
safety function. The guidance notes that to be an independent protection layer, the safeguard, “shallprevent an unsafe scenario from progressing regardless of the initiating event or the performance of

CSB · Investigation Report151another [safeguard].” Thus, the Arkema layer of protection analysis guidance prohibits safeguards
such as electrical generators, liquid nitrogen injection, and portable refrigerated trailers from being
designated as protection layers in Harvey-level flooding scenarios because flooding prevents thesesafeguards from functioning.
349. To meet the Arkema corporate risk targets for a future flooding event such as the flooding during
Hurricane Harvey, the Crosby site must be better protected from high floodwater, or the facility’ssafeguards must be modified so that they can perform their safety function even in high floodwater
depths. Potential modifications include raising the elevation of the Low Temperature Warehouses,
their electrical systems, and the backup generators, or providing a high-ground location onsite
where refrigerated trailers can be staged during the hurricane preparedness phase.

RESILIENCE FROM EXTREME WEATHER EVENTS
350. Although the flooding associated with Hurricane Harvey exceeded the design capability ofArkema’s safeguards, the CSB investigation concluded that Arkema’s safeguards could likely
provide adequate protection for a 100-year flooding event.
351. A 100-year flood with a base flood elevation of 52 feet might prevent the Crosby facility’s liquid
nitrogen system from being available because the valves and piping connections might be underwater, but other Arkema safeguards could probably operate as intended. The emergency generators
were elevated above the base flood elevation and would likely be available. In addition, 100-year
floodwater levels would be unlikely to compromise the company’s capability to relocate the organic
peroxide products to refrigerated trailers. Further risk reduction could be accomplished bymodifying the liquid nitrogen system to ensure its availability during a 100-year flood.
352. Despite the appearance that Arkema’s safeguards can withstand a 100-year flood, as the company
evaluates its options to ensure resilience from future flooding like the floodwater elevation from
Hurricane Harvey or by other extreme weather events, Arkema should also perform a thoroughreview of its programs and ensure availability of its safeguards during more frequent flooding
events.

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CSB · Investigation Report153Members of the U.S. Chemical Safety and Hazard Investigation Board:

Vanessa Allen Sutherland, J.D./M.B.A.
Chairperson

Manuel Ehrlich
MemberRichard Engler
MemberKristen Kulinowski, Ph.D.
Member154

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