SENG 312 Group 15

Andrew Bohuslav, Hana Warren, Kate Godfrey,

Emily Sturgell

Purpose
Rubber Replication Inc. plans to build a new triallyl cyanurate (TAC)
production plant near College Station, TX. TAC production is one that
involves extreme care considering the formation reaction is extremely
exothermic and involves a high reaction rate. With extremely exothermic
reactions and high reaction rates, the probability for risk and hazards is
high. With that said, Rubber Replication Inc. finds it vital to have a
strong System Safety Program Plan (SSPP) in place.
Scope
The scope of this document will include the planned tasks and
activities to be used by a contractor to implement a system safety
program (SSP).
In order to help with the understanding and implementation of this
SSPP, a case study for another TAC production plant will be referenced.
This plant, owned by MFG Chemical Inc., had an incident in April 12,
2004 that was investigated by the CSB. This investigation provided a
good stepping stone in the creation of this SSPP by highlighting issues in
the safe design and operation of a TAC production facility.
Background information regarding the TAC Process Chemistry and the
MFG Chemical case study can be found below and is included for the

TAC Process Chemistry

TAC is produced in a reaction between allyl alcohol and cyanuric
chloride. The reaction produces both TAC and HCl.
Allyl alcohol is extremely flammable; it is considered a Class IB
flammable liquid by the National Fire Protection Agency. It is highly
toxic, dangerous when inhaled, dngerous when absorbed through the
skin and an ingestion hazard. When used in quantities of 10,000
pounds or more, OSHA considers the chemical a Process Safety
Management regulated flammable liquid. In quantities of 15,000
pounds or more, the EPA considers allyl alcohol a Risk Management
Plan regulated toxic chemical.
Cyanuric Chloride is a highly reactive crystalline powder.

MFG Chemical Case Study

In attempt to manufacture TAC at an MFG Chemical Inc. plant,
located in Georgia, a catastrophic runaway reaction and toxic
chemical release to the environment occurred.
The root cause of the incident stemmed from the fact that the toplevel decision makers of the company did not investigate the
chemical reactivity of the reactants and did not anticipate the high
level of exothermic activity involved in the reaction they were
attempting to initiate. This then led to incorrect information given
to those directly involved with TAC production.
Since the reaction was not listed to produce a varying and intense
amount of heat, the contractor who installed the coolant system did
not include an adjustment mechanism to allow the employees to
control the level of coolant entering the reactor vessel. When the
initial mishap occurred, the blowing of the manway cover of the
reactor vessel, the employee who informed the local emergency
authorities did not understand the full danger of the runaway
reaction because some of the chemistry of the process was
unknown to the management and, by extension, the employees.

MFG Chemical Case Study Process Design

Policy & Objectives

Rubber Replication Inc. is committed to the safe design,
implementation, and operation of this upcoming TAC production
plant. We value employee safety and corporate responsibility to the
environment and the public. Our new operations will be held to the
highest degree of safety and environmental stewardship. We ensure
our operations meet the federal standards and compile with OSHA
regulations and EPA regulations.

Functions and Responsibilities

To show Rubber Replications dedication to the safety of this facility, a
chief safety officer will be appointed who will oversee the Safety,
Health and Environmental committees and direct the general
workings of the safety engineering staff.
Safety, Health and Environmental Committees
The Safety Committee will oversee the safe working environment and
operation of the facility and will be brought together to discuss the
main findings of the Health and Environmental Committees. This
committee will include all facility managers in order to spread safety
awareness to all facility functions.
The Health Committee will oversee compliance with OSHAs Process
Safety Management plan, dealing with the requirements for handling
hazardous substances and focusing on protecting on-site personnel.
The Environmental Committee will oversee compliance with EPAs
Risk Management Plan, with the aim of decreasing the number and
magnitude of incidents, focusing on protecting off-site people and the
environment.

Safety Engineering Staff

A safety engineering staff will be assembled and dedicated to ensuring
the smooth working of of the committees.
They will responsible for:

Committee meetings
Committee meeting minutes

Ensuring the follow through on committee meeting

decisions
Documentation of all safety related components and
incidents
Ensure OSHA recordkeeping requirements are being
met

Acquisition Responsibilities
During the acquisition of the new plant the following will be
performed during the acquisition process as part of their responsibility
to create a safe process.

Comprehensive Process Hazards Analysis

Pre-startup review

Review of Emergency Response Elements

Safety Engineering Standards

The process meets the requirements for the OSHA PSM requirements.
These requirements ensure that the systems on-going operations are
safe.
Waivers
Must be reviewed and unanimously approved by the Safety
Committee.

Hazard Reduction Precedence

Hazard Reduction Precedence is set by the hazard, which has the
highest probability of incident and will cause the most damage. Risk
determination is discussed later in the presentation.
Hazard Inspection and Abatement
The Safety Engineering Staff will keep documentation of all hazards
associated with the TAC production process. Each hazard will have
a quarterly inspection report to reassess the hazard. If the hazard
level has increased, it will be brought to the Safety Committee.
Hazard Resolution Process
All hazards of a certain hazard level are to have an adequate
timeline with milestones in order to address the lowering of the
hazard risk. This timeline is to be maintained and updated
throughout the hazard resolution process.
Hazard Tracking
All hazards will have documentation maintained by the Safety
Engineering Staff. Hazards of all kinds are to be reported and
analyzed utilizing the pyramid scheme.

System Life Cycle Safety Activities

Each system is to have a comprehensive safety evaluation during the
design, implementation and operating phases. Each phase must have a
working emergency response plan in the case that an incident occurs.
System Safety Analyses
System Safety Analyses are to be conducted every five years to comply
with OSHAs PSM regulations. Internal system safety analyses are to
be done before and after every system change.
MFG System Safety Analysis
As an example of system safety analyses, included are analyses done
for the MFG Case Study.
Trend Analysis
Utilizing Hazard Tracking, statistical analyses will be implemented to
analyze any safety and hazard trends present. All trends found are to
be brought to the attention of the Safety Committee. A re-evaluation is
be done every quarter.

Preliminary Hazard List (PHL) (Next three

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Hazard&List&
(PHL)&
slides)
System'Element'Type:'Chemicals'
Analyst:'Emily&Sturgell&

I.4.2.1.1&
Preliminary&
Hazard&
List&

No.&

PHL01&

PHL02&

PHL03&

System&
Item&

Hazard&

Hazard&
Effect&

Extremely&flammable&

Could&start&fire&in&storage&
vessel&or&reactor&

&&

Toxic&

Harmful&to&workers&who&inhale,&
contact,&or&ingest&vapors&or&
liquid&

Protection&equipment&must&be&
worn&by&all&who&handle&or&work&
near&liquid&or&vapors&

Highly&reactive&

Could&cause&runaway&reaction&

Control&rate&of&reactant&addition&to&
reactor&vessel&to&control&reaction&
speed&

Strong&irritant&

Harmful&to&workers&who&ingest&
or&touch&crystals&

&&

Spontaneously&decomposes&in&
exothermic&reaction&

Undergoes&spontaneous&
exothermic&decomposition&
reaction&at&high&temperatures&

Cooling&must&be&maintained&to&
avoid&decomposition&reaction&

Highly&flammable&

Could&start&fire&in&reactor&

&&

Strong&irritant&

Harmful&to&workers&who&inhale,&
contact,&or&ingest&vapors&or&
liquid&

Protection&equipment&must&be&
worn&by&all&who&handle&or&work&
near&liquid&or&vapors&

Toxic&

Harmful&to&workers&who&inhale,&
contact,&or&ingest&vapors&or&
liquid&

Protection&equipment&must&be&
worn&by&all&who&handle&or&work&
near&liquid&or&vapors&

Ruin&product&

Must&use&inhibitor&

Allyl&Alcohol&

Cyanuric&Chloride&

Allyl&Chloride&

Comments&

PHL04&

Triallyl&Cyanurate&

Spontaneously&polymerizes&in&
exothermic&reaction&

PHL05&

Hydrogen&Chloride&

Acidic&

May&change&chemical&

Must&use&neutralizer&

Preliminary Hazard List (PHL)

Preliminary Hazard List (PHL)

Preliminary Hazard Analysis (PHA) (Next

five pages)

Preliminary Hazard Analysis (PHA)

Preliminary Hazard Analysis (PHA)

Preliminary Hazard Analysis (PHA)

Preliminary Hazard Analysis (PHA)

System Hazard Analysis (SHA)

System: TCA Production System

No.

TLM/SCF

Hazard

System Hazard Analysis (SHA)

Analyst: Kate Godfrey

Date: 4/16/14

Causes

IMRI

SHA-1

Allyl Alcohol
Pipeline

Isolation valve
malfunction

General wear
and tear

SHA-2

Temperature control
in the reactor

Overheating

SHA-3

Allyl Alcohol Storage

Vessel

Tank leak

SHA-4

Condenser

Failure to recondense
all allyl alcohol

Reactor coolant
system breaks
Coolant levels
are too low
General wear
and tear
Valve leak
Overpressurizat
ion
Corrosion
Tube fouling
Air In-Leakage

SHA-5

Rupture Disk Relief

Valve

Early rupture
No rupture

General wear
and tear
Corrosion
Seal leak

SHA-6

TAC Storage Vessel

Residual allyl
alcohol

Condenser
failure
Inadequate
filtering
Inadequate
washing

Effects

Recommended Action

FMRI

Status

Inability to control
rate of reaction
could result in
runaway reaction
Runaway Reaction

1D

Regular inspection of
all piping

1E

Open

1C

1E

Open

Toxic chemical
release to
environment

1D

!E

Open

Pressure buildup in
condenser could
result in explosion
and toxic chemical
release

1C

1E

Open

Equipment damage
and toxic chemical
release
Overpressurization
of reactor vessel
could lead to
explosion and toxic
chemical release
Pressure buildup of
flammable toxic
chemical could
result in fires or
explosion

1C

Ensure coolant levels

can be easily adjusted
Regular inspection and
necessary maintenance
Scrubbers and other
safety equipment are
necessary
Regular inspection and
necessary maintenance
Regular inspection and
necessary maintenance
Installation of pressure
gage on condenser so
pressure can easily be
monitored
Regular inspection and
necessary maintenance
Scrubbers and other
safety equipment are
necessary

1E

Open

Regular inspection and

necessary maintenance
Installation of allyl
alcohol detectors

1E

Open

1D

Subsystem Hazard Analysis (SSHA)

System: TCA Production System

Subsystem: Reactor

Subsystem Hazard Analysis (SSHA)

No.

Hazard

Causes

Effects

SSHA1

Overpressurizatio
n

Reaction at wrong
temperature
Thermal
expansion
Valve malfunction

Runaway
reaction
Explosion
and toxic
chemical
release into
environment

SSHA2

Overheating

Reactor coolant
system breaks
Coolant levels are
too low

SSHA3

Mixing failure

Agitator motor
fails
Agitator shaft
breaks off

SSHA4

Mechanical
integrity failure

Corrosion of
reactor walls

Mode

Analyst:Andrew Bohuslav
Date

IMR
I

Recommended Action

FMR
I

Comments

Status

Reaction

1C

Regular inspection
and necessary
maintenance
Ensure cooling
system is working
properly

1E

Keep an upto-date
journal of all
inspections

Open

Runaway
Reaction

Reaction

1C

Ensure coolant levels

can be easily
adjusted
Regular inspection
and necessary
maintenance
Regular inspection
and necessary
maintenance

1E

Keep an upto-date
journal of all
inspections

Open

Unmixed
reactants may
build up to
unsafe levels
Unmixed
reactants may
fail to
produce
quality
product
Reactor leak

Mixing

1D

1E

Keep an upto-date
journal of all
inspections

Open

Reaction

1D

Regular inspection
and necessary
maintenance

1E

Keep an upto-date
journal of all
inspections

Open

System Safety in the Design Review

During the design review all members of the safety team review the
design. The design is looked at as a whole. The team discusses what
can be implemented to reduce any risks or hazards. This is a critical
step in ensuring
Change Order Review and Signatory Authority

OSHAs PSM Management of Change regulations are to be complied with. All

change orders have to be approved and signed by all facility managers. This
will ensure all subsystems of the facility are aware of the impending change.

Acquisition Test
The acquisition test requires the system to be tested. It will help ensure
the craftsmen and materials are up to the specified level. During the
testing X-ray testing of the metal and mass spectrometry of the
materials is to be conducted to ensure the system is in good condition.
During the building process it is critical that visual inspections are
performed to ensure the craftsmanship is of the proper level and all
parts are assembled correctly. These tests ensure that all contract
requirements are met.
Operational Tests
Pre-startup operation tests are to be performed prior to each startup to
ensure proper working order of the system.
Safety Test
Pre-startup safety tests are to be performed prior to each startup to
ensure proper working order of all safety equipment within the
system.

Employee's Right-to-Know
Employees have the right to know what hazardous chemicals are
present in their workplace. In addition Employees cannot be
discriminated against for asking for Material safety data sheets. This
information must be available for all employees.
Safety Awareness and Training
The company is responsible for training and keeping workers aware
of the hazards present in the work place. All new employees must
complete the Safety Awareness and Safety Training workshops
before they begin working. For established employees, it is expected
that they complete the Safety Awareness and Safety Training
workshops once a year. Documentation of attendees will be kept and
a Certificate of Attendance will be presented to the attendees.
Personnel Certification for Hazardous Operations
Employees working in close proximity to hazardous chemicals must
complete mandatory safety training specifically corresponding to the
pertinent hazardous chemical. The training will include the proper
use and maintain of the required personal protective equipment for
handling the hazardous chemical.

Risk Assessment
Risk assessment will be made using the Risk Matrix. The Risk Matrix
allows one to assess risk from the best case scenario (IVF) to the worst
case scenario (IA).

Risk Acceptance Criteria

All hazardous risks within the yellow zone are to be monitored and
maintained but not acted upon unless deemed worthy by the Safety
Committee. All hazardous risks within the orange and red zone are to
be addressed by the Safety Committee.

Employee Acceptance
Employee acceptance of the risk is accomplished by informing the
workers of the risk and ensuring the risk is below the level at which
their compensation allows them to accept these risk.
Public Acceptance
Public acceptance is gained by demonstrating the process safety to the
public. This is done by community outreach and other educational
programs which explain the process and steps taken to reduce the risk
to an acceptable level.

Reporting the Accident

An internal investigation should begin within 24 hours of the incident
and should include the following:

The date of the incident

The time of the incident
A description of the incident
The root causes contributing to the incident
The casual factors contributing to the incident
Recommendations to reduce the likelihood of similar

incidents
A timeframe to follow through with the
recommendations

Forming an Investing Board

The investigation board should include those knowledgeable of the

Documenting the Accident

The incident investigation report is to include a diagram
detailing the root causes and causal factors contributing to the
incident. A Swiss Cheese Model and Fault Tree Analysis are
highly suggested.

Swiss Cheese
Model

Runaway
Reaction

Failure to
Understand the
Reactive chemistry

Did not
Use available
Literature

Failure to
Anticipate reactive
Chemistry

Did not
Did not
conduct c
conduct c
Did not
Comprehensive Comprehensive Use available
literature
literature
Literature
search
search

Fault Tree Analysis for

Runaway Reaction

Did not perform

a design review

Coolant
Failure

Improper Reaction
Mixture

Added to
Much
Product

Added
A Catalyst

Hazardous
Release

Failure to
implement
Response plan

Did not train

employees

Did equip
employees

Failure to implement
EPA risk Management
Program

Create an
Emergency
Plan

Fault Tree Analysis for

Hazardous Release

Pre-Startup
Safety
Review

Safety Systems
Did not active

Coordination
With
Community

Rupture
Disk Failure

Disk
improperly
Sized

Man way
Not
secured

Coolant
System
Failure

Corrective Action & Verification of Corrective Action

The incident investigation report is to include:

Recommendations to reduce the likelihood of similar

incidents
Recommendations for each root cause
Recommendations for each causal factor
Timeframe detailing when each recommendation
should be implemented, based on the severity of the
risk being reduced.

OSHA and EPA Mishap Notification Reporting and Record Keeping

OSHA and EPA are to be notified within 24 hours of the incident, in
compliance with regulations.
Informing the Public
A public announcement is to be made within 48 hours of the incident.
The incident investigation report is to be made public within one

Emergency Preparedness and Response Analysis

Written procedures for an emergency are to be prepared and posted
around the TAC production facility
Key members must be trained, equipped and drilled quarterly in their
roles
During TAC production the release of toxic allyl alcohol and allyl
chloride could be catastrophic without proper emergency plans.
Emergency Response and Community Services
The emergency response plan is to be shared with the public and
surrounding community. The local emergency response teams (i.e.
Fire department and police department) should also be informed of
the emergency plan.
This ensure public safety in the case of an emergency.

Emergency Preparedness Training

Quarterly emergency response drills must be conducted by the entire
facility, alternating each quarter between day and night shifts.
New facility personnel and visitors must be individually trained in the
emergency response plan, and pass an emergency response test.
All facility personnel must take a refresher course on the emergency
response plan each year.
Should the emergency response plan undergo a change by the
approval of the Safety Committee, retraining of all facility personnel in
the emergency response plan is to be implemented ASAP.

Hazardous Materials and Chemical Control

Standards are to be created in compliance with OSHAs PSM
regulations.
Standards must be posted around the facility.
Environmental Compliance Control
Standards are to be created in compliance with EPAs RMP regulations
and any local environmental regulations.
Standards are to be posted throughout the facility.
Occupational Health
Standards are to be created in compliance with OSHAs PSM
regulations.
Standards must be posted around the facility.

Oversight and Methods

It is required that each subcontractor submit a proper safety plan. It
must be reviewed and then unanimously agreed upon by the safety
committee.
Each subcontractor safety plan must follow all the requirements,
standards and regulations set in place by the safety committee. If it
does not, it will not be approved.
Self-Evaluations
Self-Evaluations will be completed regularly and without
repercussions, these will allow workers the chance to look at their
work environment and work routine for hazards.
This will allow another chance to document near misses. This
information is vital in the tracking of potential problems before they
become hazards.
This lends itself to the principle of if you see something, say
something.

Evaluation of Transient Contractors

All contractors must complete onsite training and prove competence
in work to be completed.
Each new Contractor must meet with the on site safety team and have
a working understanding of the hazards in the workplace.
In addition each contractor must be trained in all necessary PPE.
Holding transient contractors to this level of safety reduces the
likelihood of something such as the manway cover improperly sealed
becoming a standard problem.

Documentation and Configuration Control

The Safety Engineering staff is to maintain OSHA PSM recordkeeping
standards.
Preparing for Internal Safety Audits
Internal safety audits are to be performed yearly. Should a changeorder occur, a safety audit is to be performed regardless of how
recently one was performed.
OSHA Audits
OSHA Audits are to be helped and facilitated.

Hazardous Operations Procedures

TAC production requires four basic hazardous operations:

The handling of allyl alcohol

The handling of cyanuric chloride
The mixing of the two chemicals
The handling of the product. TAC production requires

four basic hazardous operations:

Allyl alcohol is an extremely flammable, toxic chemical which should

be handled in accordance with OSHA PSM regulations 29 CFR
1926.152.
Cyanuric chloride is extremely reactive and a strong irritant, and thus
should be handled with extreme care.
Mixing the reactants should be done in a rate-controlled manner and
overseen by someone with a working understanding of the chemistry
of TAC synthesis
Protective equipment including gloves, eye protection, long sleeves,

Construction Safety
During construction of the facility and subsequent construction
projects, someone with a thorough understanding of the chemistry of
TAC synthesis and the high energies and heat associate with the
reaction should approve all operational and equipment changes that
involve the chemicals in question.
In addition, the Safety, Health, and Environmental Committees must
approve all operational alterations and equipment changes for
construction purposes.
Safety Design Requirements
The Design of the system must meet minimum safety Requirements.
These include the addition of relief valves and motioning equipment.
These design Requirements must incorporate the OSHA elements of
PSM.

[1]. Ericson, Clifton A. Hazard Analysis

Techniques for System Safety. Hoboken, NJ:
Wiley-Interscience, 2005. Print.
[2] Bahr, Nicholas J. System Safety Engineering
and Risk Assessment: A Practical Approach.
Washington, DC: Taylor & Francis, 1997. Print.
[3] U.S. Chemical Safety And Hazard
Investigation Board, 2006, Investigation Report:
Toxic Chemical Vapor Cloud Release at MFG
Chemical, Inc., (Report No. 2004-09-I-GA)
[4] Occupational Safety and Health