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E PL UR IBU S UNUM

NATIONAL TRA S PORTATIO

N

BOARD

SAFE T Y

N

National Transportation Safety Board

Washington, D.C. 20594

Hazardous Materials Accident Brief

Accident No: DCA99MZ003

Location: Louisville, Kentucky

Date of Accident: November 19, 1998

Time: 8:15 a.m. eastern standard time

Carrier: Matlack, Inc.

Vehicles: MC-307 Cargo Tank

Injured: 7 minor

Evacuated: About 2,400 people were evacuated from the plant and

surrounding business. About 600 local residents were told

by authorities to remain inside their homes.

Property Damage: In excess of $192,000

Materials Involved: Nickel nitrate and phosphoric acid solution reacting with

sodium nitrite solution

Type of Accident: Chemical reaction during cargo transfer

The Accident

About 7:15 a.m. eastern standard time on November 19, 1998, a truckdriver

driving a Matlack, Inc., cargo tank truck arrived at Ford Motor Company’s Kentucky

Truck Plant in Louisville, Kentucky, to deliver a liquid mixture of nickel nitrate and

phosphoric acid (a solution designated CHEMFOS 700 by the shipper).

A plant employee told the truckdriver to park his vehicle next to the chemical

transfer station outside the bulk storage building and wait for a pipefitter to assist him in

unloading the chemical. According to testimony, a short time later, the pipefitter arrived at

the transfer station and told the driver that he would assist him in unloading the cargo

tank. The pipefitter opened an access panel containing six identical pipe connections. Each

pipe connection served a different storage tank, and each connection was marked with the

plant’s designation for the chemical stored in that tank.

The driver told the pipefitter that he was delivering CHEMFOS 700 and then went

to the driver’s side of the cargo tank and took out a cargo transfer hose. The pipefitter

connected one end of the hose to one of the transfer couplers, while the driver connected

the other end of the hose to the cargo tank’s discharge fitting. Unknown to the pipefitter

or the truckdriver, the pipefitter had inadvertently attached the hose to the coupler marked

“CHEMFOS LIQ. ADD” instead of to the adjacent coupler marked “CHEMFOS 700.”

The storage tank served by the coupler marked “CHEMFOS LIQ. ADD” contained

sodium nitrite solution.
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The driver climbed to the top of the cargo tank, connected a compressed air hose

to a fitting, and pressurized the cargo tank. The driver and the pipefitter then reviewed the

cargo manifest and bill of lading. The pipefitter signed three different certifications on the

cargo manifest, one of which certified that the transfer hose was “connected to the proper

receiving line.” The pipefitter asked the driver how long it would take to unload the

contents of the cargo tank, and the driver told him the transfer would take about 30 to 40

minutes. The pipefitter then left the loading area, leaving the driver to complete the

unloading by himself.

About 8:15 a.m., after the air pressure was built up in the cargo tank, the

truckdriver started the transfer. When the nickel nitrate and phosphoric acid solution from

the truck mixed with the sodium nitrite solution in the storage tank, a chemical reaction

occurred that produced toxic gases of nitric oxide1 and nitrogen dioxide.2 The driver

stated that about 10 minutes after he started the transfer, he saw an orange cloud coming

from the bulk storage building. (See figure 1.) He said he closed the internal valve of the

cargo tank to stop the transfer of cargo and waited for someone to come out of the

building. After several minutes, the pipefitter ran out of the building and gestured for the

driver to stop the unloading process.

Figure 1. Postaccident view of the bulk storage building (center) with vapor cloud visible

As a result of the incident, about 2,400 people were evacuated from the plant and

surrounding businesses, and another 600 local residents were told by authorities to remain

 

1

 Nitric oxide is toxic when inhaled and is a strong irritant to skin and mucous membranes.

2

 Nitrogen dioxide may be fatal if inhaled.
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inside their homes. Three police officers, three Ford Motor Company employees, and the

truckdriver were treated for minor inhalation injuries. Damages exceeded $192,000.

Chemical Transfer System

The chemical transfer station for unloading cargo tanks was on the outside of the

bulk storage building. The system consisted of six 2-inch pipe connections enclosed in an

access panel. (See figure 2.) The connections were identical stainless steel quick-connect

couplers, and each had a shutoff valve. Each connection led to a different chemical storage

tank. The couplings were not equipped with caps or locks, nor could the access panel be

secured when the system was not in use.

Figure 2. Transfer coupler access panel with transfer

hose attached
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The connection for the nickel nitrate and phosphoric acid solution was labeled

“CHEMFOS 700” in black print on a yellow background. An identical adjacent pipe had

similar labeling, but the wording on the label was “CHEMFOS LIQ. ADD,” which was

partially obscured by tape. (See figure 3.)

Figure 3. Close-up view of the correct transfer coupler (left) and the coupler to which

the transfer hose was inadvertently attached (right)

Training for Unloading Operations

At the time of the accident, Ford Motor Company had written procedures for

unloading cargo tanks at its Louisville truck facility and a training program for employees

involved in unloading bulk chemicals. On June 26, 1998, the pipefitter involved in this

accident received training covering Local Work Instruction No. EI100-3, dated May 26,

1998. This work instruction had been revised on June 23, 1998, and certain requirements

had been added that were to be met during the unloading process. These new

requirements included covering storm drains in the unloading area, verifying that sufficient

capacity is available in the holding tank, and remaining with the truckdriver to observe the
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unloading process. The pipefitter did not receive training on the revised local work

instruction or its new requirements before the accident.

According to the company’s manufacturing process engineer, another written

company instruction included a step-by-step procedure for unloading bulk tankers. This

procedure was developed to meet the company’s ISO3 9000 certification process in May

1997. This unloading procedure was not disseminated to Ford Motor Company pipefitters

responsible for the unloading of cargo tanks; it was placed in the company’s phosphate

process manual, and the process engineer said he advised the pipefitters to review it. The

procedure was also posted on a bulletin board inside the bulk storage building. According

to interviews, the company did not train the pipefitters on the written unloading

procedure, which included the requirement to double-check connections to verify the

proper connection.

The pipefitter stated that he was unaware of any written instructions or procedures

covering the unloading of a cargo tank. Training records did indicate that the pipefitter

had been given a copy of Local Work Instruction No. EI100-3, dated May 26, 1998. He

further stated that if he had double-checked the connection before he left the transfer area,

he probably would have noticed that the transfer hose was connected to the wrong

coupling.

Regulatory Requirements

Title 49 Code of Federal Regulations (CFR) Section 172.702 requires hazmat

employers to train and test their hazmat employees. Under Section 172.704, hazmat

employers are required to provide general-awareness, function-specific, and safety training

to employees who perform functions related to the transportation of hazardous materials.

The term “hazmat employee,” as defined in 49 CFR §171.8, includes all persons

who in the course of employment perform functions that directly affect hazardous

materials transportation safety. According to the interpretation of the U.S Department of

Transportation’s (DOT’s) Research and Special Programs Administration (RSPA), the

employee’s functional relationship to hazardous materials transportation safety, rather than

incidental contact with hazardous materials in the work place, is the primary factor in

determining whether an individual is a “hazmat employee.”

The Safety Board contacted the acting director for the DOT’s Office of Motor

Carrier Safety (OMC)4 to determine the scope of its enforcement of the hazardous

materials regulations (HMR) by OMC’s investigators at facilities that receive hazardous

materials shipments. The OMC official replied that “OMC has no jurisdiction to perform

 

3

International Standards Organization.

4

 On January 1, 2000, the Office of Motor Carrier Safety was redesignated the Federal Motor Carrier

Safety Administration.
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investigations of facilities that receive hazardous materials.” Neither the OMC nor RSPA

had conducted compliance reviews at the Louisville, Kentucky, truck plant.

As a result of its investigation of a 1986 marine accident in Deer Park, Texas,

which involved a transfer of hazardous materials between a marine vessel and a transfer

terminal, the Safety Board pointed out the need for the DOT to establish uniform general

requirements that would provide adequate and equal levels of safety for the public and for

employees of all segments of a hazardous materials transportation system. As a result of the

Deer Park accident investigation, the Safety Board issued intermodal Safety

Recommendations I-88-1 and -2, asking the DOT to establish safety requirements for the

movement and temporary storage of hazardous materials at intermodal transportation

facilities and to strengthen the minimum safety requirements for loading and unloading

hazardous materials in all modes of transportation. In issuing these safety

recommendations, the Safety Board noted that in the Transportation Act of 1974

(Hazardous Materials Transportation Act), Congress defined transportation as “any

movement of property by any mode, and any loading, unloading, or storage incidental

thereto.”

According to Safety Board records, the Board has not received any

correspondence from the DOT regarding Safety Recommendation I-88-1 since

January 14, 1994, and regarding Safety Recommendation I-88-2 since September 30,

1988. In response to Safety Recommendation I-88-1, the DOT indicated that RSPA had

initiated a review of jurisdictional authority that was to have been completed by December

31, 1988. In response to Safety Recommendation I-88-2, the DOT indicated that loading

and unloading operations were being addressed in several regulatory projects by the

different DOT modal administrations. According to Safety Board records, no information

has been received to indicate that the review of jurisdictional authority by RSPA or the

other regulatory projects cited by the DOT were completed. Safety Recommendations

I-88-1 and -2 remain classified “Open—Unacceptable Response.”

On July 29, 1996, RSPA published an advance notice of proposed rulemaking

(ANPRM) titled “Applicability of Hazardous Materials Regulations (HMR) to Loading,

Unloading, and Storage,” Docket No. HM-223. The ANPRM announced three public

meetings at which RSPA would “seek ideas, proposals and recommendations regarding

the applicability of the HMR to particular hazardous materials transportation activities.”

This information would “help the agency to consolidate, clarify, revise and update existing

agency interpretations, rulings and decisions regarding the applicability of the HMR and

determine whether there is a need to amend the HMR.” On April 27, 1999, RSPA

published a supplemental ANPRM for Docket No. HM-223 to “highlight comments

received” in response to the ANPRM and to invite additional comments on the

applicability of the HMR to the loading, unloading, and storage of hazardous materials.

RSPA has indicated that it will issue a notice of proposed rulemaking later in 2000 that

addresses the loading, unloading, and storage of hazardous materials.

Although RSPA has not published a final rule for HM-223, the policy of the

Federal Railroad Administration (FRA) is to inspect and enforce the HMR at all facilities
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that receive hazardous materials shipments by rail. These facilities include shipping

(loading), carrier (railroad operator), and unloading (consignee) facilities. According to

documentation provided to the Safety Board by the FRA, that agency has issued

hazardous materials bulletins that specify FRA policy and guidance for industry in specific

areas. These bulletins have been included in FRA inspectors’ Hazardous Materials

Enforcement Manual. Examples of some bulletin topics are tank car unloading, attendance

requirements, and hazardous materials training requirements. Each of these bulletins

suggests specific procedures to be followed in the topical area. Further, the FRA has

published guidance documents for industry’s use in developing effective railroad tank car

loading and unloading training programs. The FRA conducts “cursory reviews of the

training received by hazmat employees after completion of their training to ensure that

each hazmat employee is trained, tested, and certified on the employee’s appropriate area

of responsibility.”

Actions Taken Since The Accident

According to Ford officials, the company now requires that before a cargo tank

can be unloaded, the proper connection of the transfer hose must be verified by specially

trained company personnel, the truckdriver, and an on-site chemical supplier employee (if

available). The company has also upgraded the signs at transfer stations, installed colorcoded key locks on pipe end caps, installed locks on the access panel, and posted

unloading instructions at the transfer station.

Probable Cause

The National Transportation Safety Board determines that the probable cause of

this accident was inadequate training of Ford Motor Company’s employees on the

company’s procedures for unloading bulk hazardous materials. Contributing to the

accident was the similar labeling of adjacent pipe connections, which made it possible for

the pipefitter to confuse the two connections. Further contributing to the accident was the

failure of the U.S. Department of Transportation to establish, and oversee compliance

with, adequate safety requirements for unloading hazardous materials from highway cargo

tanks.

Adopted: June 20, 2000
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Recommendations

As a result of its investigation of the November 19, 1998, accident in Louisville,

Kentucky, and the June 4, 1999, accident in Whitehall, Michigan,5 the Safety Board issues

the following safety recommendations:

To the Research and Special Programs Administration:

Within 1 year of the issuance of this safety recommendation, complete

rulemaking on Docket HM-223 “Applicability of the Hazardous Materials

Regulations to Loading, Unloading and Storage,” to establish, for all

modes of transportation, safety requirements for loading and unloading

hazardous materials. (I-00-6)

To the Occupational Safety and Health Administration:

Require that facilities where bulk hazardous materials are transferred be

equipped with a means of emergency communications. (I-00-7)

To Ford Motor Company:

Distribute written safety-critical procedures for unloading bulk shipments

of hazardous materials to all Ford Motor Company employees who are

engaged in cargo transfer operations, and conduct initial and recurrent

training on the procedures. (I-00-8)

To the American Chemistry Council:

Revise, in cooperation with National Tank Truck Carriers, Inc., the

Manual of Operating Recommendations to include specific recommended

practices that can be implemented to prevent the unloading of hazardous

materials into the wrong storage tank. For example, drivers should

personally verify or question all transfer connections before beginning

delivery of product. (I-00-9)

 

5

 National Transportation Safety Board. 2000. Chemical Reaction During Cargo Transfer. Hazardous

Materials Accident Brief HZB/00/03. Washington, D.C.
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Inform your members of the facts and circumstances of the June 4, 1999,

accident in Whitehall, Michigan, and the November 19, 1998, accident in

Louisville, Kentucky, and emphasize the importance of implementing

specific safety-critical hazardous materials cargo transfer procedures and

training employees in those procedures. (I-00-10)

To National Tank Truck Carriers, Inc.:

Revise, in cooperation with the American Chemistry Council, the Manual

of Operating Recommendations to include specific recommended practices

that can be implemented to prevent the unloading of hazardous materials

into the wrong storage tank. For example, drivers should personally verify

or question all transfer connections before beginning delivery of product.

(I-00-11)

Inform your members of the facts and circumstances of the June 4, 1999,

accident in Whitehall, Michigan, and the November 19, 1998, accident in

Louisville, Kentucky, and emphasize the importance of implementing

specific safety-critical hazardous materials cargo transfer procedures and

training employees in those procedures. (I-00-12)