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Assessment of Approaches for Using Process Safety Metrics at the Blue Grass and Pueblo Chemical Agent Destruction Pilot Plants Summary DESTRUCTION OF THE U.S. CHEMICAL STOCKPILE The Department of Defense, through the Assembled Chemical Weapons Alternatives (ACWA) program, is currently in the process of constructing two full-scale pilot plants at the Pueblo Chemical Depot in Colorado and the Blue Grass Army Depot in Kentucky to destroy the last two remaining inventories of chemical weapons in the U.S. stockpile. Destruction of this stockpile, originally comprising over 31,000 tons of chemical agents stored at eight chemical weapons depots in the continental United States and on Johnston Island in the Pacific Ocean (southwest of Hawaii), has been ongoing for two decades, and is being performed in accordance with requirements of the Chemical Weapons Convention treaty, to which the United States is a signatory. Approximately 10 percent of the original stockpile is stored at the Pueblo Chemical Depot and the Blue Grass Army Depot, with approximately 90 percent stored at sites being served by the U.S. Army Chemical Materials Agency (CMA) disposal facilities. As of January 12, 2011, the CMA had destroyed 83 percent of the stockpile being treated at its facilities.1 Disposal operations at the six other continental U.S. sites and Johnston Island, managed by the CMA, either have been completed or are nearing completion. The disposal facilities at these sites were either based on incineration technology to destroy the chemical agents and associated energetics (propellants and/or explosives) or used chemical neutralization (hydrolysis) to destroy nerve and mustard agents stored in bulk containers. In contrast, the Pueblo and Blue Grass Chemical Agent Destruction Pilot Plants (PCAPP and BGCAPP) will use neutralization technology to destroy the agents that are contained in various types of assembled chemical munitions—that is, rockets, projectiles, and mortar rounds. Consequently the processing equipment employed at PCAPP and BGCAPP will be newer or of different design than the equipment at the other disposal facilities. These pieces of process equipment are referred to as first-of-a-kind (FOAK) equipment. The FOAK equipment the committee believes could pose the most significant challenges to operations at PCAPP and BGCAPP is described in Table S-1. For reasons such as the use of FOAK equipment and, more broadly, in recognition of the need to conscientiously adhere to congressional mandates that destruction of chemical agent and munitions be executed with maximum protection for workers, the public, and the environment, the Program Manager for Assembled Chemical Weapons Alternatives requested that the National Research Council (NRC) undertake a study to guide the development and application of process safety metrics for PCAPP and BGCAPP. Another reason for requesting this report was the NRC report issued in 2009 Evaluation of Safety and Environmental Metrics for Potential Application at Chemical Agent Disposal Facilities, which responded to a request by the CMA for recommendations on additional metrics 1 See http://www.cma.army.mil/home.aspx for updated information as the program progresses.
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Assessment of Approaches for Using Process Safety Metrics at the Blue Grass and Pueblo Chemical Agent Destruction Pilot Plants TABLE S-1 First-of-a-Kind Equipment and Processes That Could Pose Significant Challenges for PCAPP and BGCAPP FOAK Equipment Site(s) Function Notes Rocket cutting machine (RCM) BGCAPP To separate rocket motors from the warhead. This is an entirely new piece of equipment. Linear projectile mortar disassembly (LMPD) machine BGCAPP PCAPP To disassemble projectiles and mortars and remove their bursters. This is a new unit that replaces the PMD machine used at the baseline incineration sites operated by CMA. Munitions washout station (MWS) BGCAPP PCAPP To remove the burster well from projectiles, drain the chemical agent, and wash out any agent residues. This is an entirely new piece of equipment. It replaces the PMD machine used at the baseline incineration sites operated by CMA. Energetics batch hydrolyser (EBH) BGCAPP To neutralize energetics and any chemical agent in the metal parts of the rockets and fuzes from projectiles. This is an entirely new piece of equipment. Metal parts treater (MPT) BGCAPP To decontaminate projectile bodies and secondary waste by heating to over 1000°F for more than 15 minutes. This is an entirely new piece of equipment. Munitions treatment unit (MTU) PCAPP To decontaminate projectile bodies and secondary waste by heating to over 1000°F for more than 15 minutes. This is an entirely new piece of equipment. Supercritical water oxidation (SCWO) BGCAPP To treat agent and energetics hydrolysates before releasing them for final disposal. This is an entirely new piece of equipment and process. Immobilized-cell bioreactors (ICBs) PCAPP To treat mustard hydrolysate before releasing it for final disposal. This is an entirely new piece of equipment and process. that could further improve the safety and environmental programs at those sites. The statement of task for the Committee to Assess Process Safety Metrics for the Blue Grass and Pueblo Chemical Agent Destruction Pilot Plants (the committee) is the following: The National Research Council will establish an ad hoc committee to: Review and evaluate plans for the use of process safety metrics to be employed at the two Assembled Chemical Weapons Alternatives (ACWA) pilot plant facilities, Examine and assess the process safety metrics used in commercial and industrial operations for potentially applicable process safety metrics, and Assess new initiatives at national organizations (i.e., American Institute of Chemical Engineers, etc.) that could be used by ACWA. As previously indicated, both PCAPP and BGCAPP will use chemical neutralization technology instead of incineration to destroy chemical agents and, in the case of BGCAPP, to destroy certain energetics. Neutralization involves the hydrolysis of chemical agent and energetics using hot water for mustard agent and caustic for nerve agent and energetics. PCAPP plans to ship the energetics removed from munitions for disposal offsite and will use biotreatment to destroy the products of mustard agent neutralization, known as hydrolysate. BGCAPP will use neutralization followed by the treatment of the resultant agent and energetics
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Assessment of Approaches for Using Process Safety Metrics at the Blue Grass and Pueblo Chemical Agent Destruction Pilot Plants hydrolysates by supercritical water oxidation.2 Implementation of these primary and secondary destruction methods also entails numerous ancillary processes and activities—for example, munitions disassembly and waste management, which in turn require the use of additional FOAK equipment and processing. The term FOAK implies the use of new technologies or new applications of existing technologies that could be problematic with respect to functionality, reliability, availability, and maintainability. This means that adjustments ranging from procedural modifications to varying degrees of redesign might be required as such equipment is developed, tested, and integrated into actual agent processing operations. One example of FOAK equipment, the linear projectile mortar disassembly machine, is undergoing testing at the Anniston Chemical Agent Disposal Facility. As a result of this testing, 164 specific operating criteria have been reviewed, 20 documented lessons learned will be applied to the design and operation of the system at PCAPP, and more than 110 significant code changes have been identified. Although not all FOAK equipment will be tested in an operational setting prior to systemization, as the linear projectile mortar disassembly machine has been, laboratory testing and evaluation of all FOAK equipment is performed to identify issues and needed adjustments before the equipment is placed in operation. PCAPP and BGCAPP will both undergo preoperational systemization before starting actual agent disposal operations. Systemization involves progressive testing—from the demonstration of components to subsystems to the entire system, using surrogate munitions—to bring each system to its fully operational design function. Both facilities will follow a progression of steps consisting of the installation of process equipment, integration of process equipment, and overall plant operation using agent surrogates instead of actual chemical agent. During this phase of the project, the systems used to operate the plant will be tested and configured. BACKGROUND INFORMATION RELATED TO PROCESS SAFETY METRICS There are two types of process safety metrics: leading and lagging.3 Defining appropriate and effective leading and lagging process safety metrics has been a subject of great interest in recent years, particularly in the chemical and petroleum industries, since those industries handle or produce reactive, toxic, and flammable materials that, if released, can cause multiple fatalities and/or injuries and have significant environmental consequences. Further details on efforts to formalize and implement industrywide approaches to process safety metrics are provided in Chapter 4. A good example of a lagging process safety metric that has been in use for over a decade is the number of unplanned major chemical or energy releases. This metric has included unintended releases of hazardous chemicals that exceed the threshold quantity listed in 40 CFR 302.4, which designates CERCLA4 hazardous substances or events that result in serious injury or damages in excess of $25,000. While many of the processes that will be employed for the disposal of chemical agent and munitions at PCAPP and BGCAPP are fundamentally different from those used at the other chemical agent disposal facilities, some similarities do exist with the processes that have been employed at those sites. The committee believed that evaluating the experience with process incidents at those other sites could prove useful and would offer guidance on what process safety metrics might be useful for PCAPP and BGCAPP. The committee further believed that an analysis of relevant chemical events at those sites could provide insights on the process steps and operational systems that are most subject to failure, and might identify opportunities where the use of leading and lagging metrics could help to prevent failures. The NRC Committee on Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities (the chemical events committee) examined documentation on all of the chemical events that had occurred since commencement of destruction operations through the end of 2001 and issued its report, Evaluation of Chemical Events at Army Chemical Agent Disposal 2 Neutralization was used to destroy the chemical agents at two other sites, at Aberdeen Proving Ground, Maryland, and Newport, Indiana. These two sites, however, had only bulk agent stored in ton containers, not assembled munitions. 3 “Leading metric” and “lagging metric” are defined in Appendix A. 4 CERCLA is the Comprehensive Environmental Response, Compensation, and Liability Act, commonly known as Superfund; 40 CFR 302.4 lists dangerous chemicals and gives threshold quantities for the purpose of defining a process safety incident.
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Assessment of Approaches for Using Process Safety Metrics at the Blue Grass and Pueblo Chemical Agent Destruction Pilot Plants Facilities, in 2002. The present committee reviewed that report to identify which of the events could be classified as process incidents. It also requested an update on process-related chemical events from all currently operating sites and from the sites that completed destruction after 2001. Significantly, the frequencies of incident types, activities, and causal factors for process-related chemical events since 2001 mirror those that were noted in the 2002 Chemical Events report. From these data, it appears that the frequency and type of factors that cause process safety events are independent of the type of facility (neutralization or incineration), the type of chemical weapon (mustard agent or nerve agent), or how the agent is stored (in assembled munitions or bulk). Consequently, PCAPP and BGCAPP can reasonably be expected to experience the same types of events that have similar causal factors. However, because the processes to be employed at PCAPP and BGCAPP are unique, and FOAK equipment will be used extensively, it may be reasonable to expect more events at the outset and a possible shift in the frequency of causal factors. For example, design deficiencies might be more prevalent in new facilities with new equipment, processing steps, and unit operations than in older or second-generation facilities using proven, refined technologies and processes. Some of the personnel who will systemize and operate PCAPP and BGCAPP will come from operating chemical demilitarization facilities, providing an experience base in chemical demilitarization at the two sites. DERIVING PROCESS SAFETY METRICS RELEVANT TO PCAPP AND BGCAPP The committee’s examination of causal factors related directly to earlier experience with chemical agent and munition destruction provides an excellent basis for the development of process safety metrics at PCAPP and BGCAPP. Some key causes of process safety incidents at former and currently operating chemical agent disposal facilities identified from that experience are discussed below. Standard operating procedure (SOP) deficiencies. SOP deficiencies were the most prevalent causal factor identified, approximately 27 percent of the total. For PCAPP and BGCAPP, developing and implementing metrics that enable early identification and avoidance of deficiencies in SOPs could be very useful. Equipment malfunction. This was the second most prevalent causal factor at other chemical agent disposal facilities, approximately 26 percent of the total. While the definition of equipment malfunction used at these facilities did not include design deficiencies, it should be noted that design deficiencies caused equipment malfunctions in some instances. Equipment malfunctions and design deficiencies together were involved in approximately 31 percent of the total incidents reviewed. Conducting design audits and basing metrics on the results could assist in finding design deficiencies before they cause an equipment malfunction or other process incidents or upsets. A system of process safety-critical equipment inspections is key to minimizing equipment malfunctions. Human factors (human error, mindset, and improper technique). Human factors, which include the three causal factors listed in the parentheses above, altogether accounted for approximately 37 percent of the causal factors. Metrics derived from training activities and job cycle checks could be useful in developing actions to mitigate these types of causal factors and to identify areas where annual or more frequent periodic training should be improved or changed. Communications deficiencies. This causal factor made up approximately 4 percent of the total. These types of deficiencies are not typically documented until after a failure, but they should be considered as integral to a full complement of process safety metrics. Among the possibilities are audits of communications systems (active and passive) and documenting communications failures. Based on experience, a number of leading metrics recommended in the documents of the Center for Chemical Process Safety and the American Petroleum Institute and discussed in Chapter 4 could also be relevant to PCAPP and BGCAPP. These leading metrics include process safety near-miss events, closure of action items, completion of emergency response drills, management of change, and metrics related to other management systems. Managerial leadership is responsible for setting the tone and articulating performance expectations in an organization. When process safety metrics are set for an organization, the operation’s line leadership must
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Assessment of Approaches for Using Process Safety Metrics at the Blue Grass and Pueblo Chemical Agent Destruction Pilot Plants set performance milestones and regularly review the operation’s performance against those milestones with the organization’s managerial leadership. Furthermore, the chemical, petroleum, and related industries have learned that maintaining a staff of trained process safety professionals is vital to the avoidance of process incidents. Several other industries—for example, the nuclear power industry—and government facilities engaged in hazardous processes have been hiring full-time staff members to develop and monitor their process safety programs, although they have not done so as quickly as the chemical and petroleum industries. FINDINGS AND RECOMMENDATIONS All of the committee’s findings and recommendations are listed below. They are numbered according to their order in the chapters in which they appear. Finding 2-1. Because of the unique nature of the processes at the Pueblo Chemical Agent Destruction Pilot Plant and the Blue Grass Chemical Agent Destruction Pilot Plant and the extensive use of first-of-a-kind equipment, the use of both leading and lagging process safety metrics will be important in achieving the congressional mandate to safely destroy the chemical weapons stockpiles at the respective sites. Systemization affords an excellent opportunity to implement and evaluate leading and lagging process safety metrics. Recommendation 2-1. During systemization, the Program Manager for Assembled Chemical Weapons Alternatives should develop and implement extensive process safety metrics that can be evaluated for relevance and utility. Metrics that are found to be meaningful should be carried forward to operations. While both leading and lagging metrics should be developed and implemented to the extent possible, both the Pueblo Chemical Agent Destruction Pilot Plant and the Blue Grass Chemical Agent Destruction Pilot Plant should emphasize developing leading metrics to guide them in process safety management. Finding 3-1. The causal factors involved in past events at chemical agent disposal facilities are not process specific. Consequently, the Pueblo Chemical Agent Destruction Pilot Plant and the Blue Grass Chemical Agent Destruction Pilot Plant can reasonably be expected to experience the same types of events having causal factors similar to those experienced at the Chemical Materials Agency sites. Also, there may be an increase in the frequency of events and a shift in the relative frequency of causal factors. Finding 4-1. At the present time, there is no definition of a process safety incident other than “release of agent” within the Assembled Chemical Weapons Alternatives program. Establishing or adopting a common definition for process safety incidents would improve consistency of reporting and sharing of lessons learned within the program. Recommendation 4-1. The Program Manager for Assembled Chemical Weapons Alternatives should adopt the definitions of Tier 1-4 process safety events in Recommended Practice 754, Process Safety Performance Indicators for the Refining and Petrochemical Industries, a joint recommendation of the American National Standards Institute and the American Petroleum Institute, with the exception that the reporting threshold for chemical agents should be defined as any unintended release. Finding 4-2. Developing metrics for the Pueblo Chemical Agent Destruction Pilot Plant and the Blue Grass Chemical Agent Destruction Pilot Plant based on operating experience at other chemical agent disposal facilities would help to avoid failures that lead to process safety incidents. Recommendation 4-2. The Program Manager for Assembled Chemical Weapons Alternatives should take into account the causal factors in past process safety incidents at chemical agent disposal facilities when devising process safety metrics for the Pueblo Chemical Agent Destruction Pilot Plant and the Blue Grass Chemical Agent Destruction Pilot Plant. Finding 4-3. Many process safety metrics that could be used by the Pueblo Chemical Agent Destruction Pilot Plant and the Blue Grass Chemical Agent Destruction Pilot Plant are available to the public, including those in the list of metrics in the Center for Chemical Process Safety publication Guidelines for Process Safety Metrics. These metrics could complement process-specific metrics developed at the respective sites. Recommendation 4-3. The Pueblo Chemical Agent Destruction Pilot Plant and the Blue Grass Chemical
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Assessment of Approaches for Using Process Safety Metrics at the Blue Grass and Pueblo Chemical Agent Destruction Pilot Plants Agent Destruction Pilot Plant should adopt the metrics listed below and develop process-specific leading and lagging metrics. The ACWA program should also consider a metric associated with emergency planning and response as well as published lists of process safety metrics and should adopt those that appear to be of value to these sites. Count of process safety near-miss events. Training records such as validation of job cycle checks and completion of training, including refresher training. Job procedures: Statistics on whether a procedure was used and, if it was, was the procedure the correct one? Validation that procedures are current and accurate. Statistics on the closure of action items. Percent of inspections of safety-critical equipment completed on time. Percent of sampled management of change instances that met all requirements and quality standards. Finding 4-4. The United Kingdom Health and Safety Executive’s Health and Safety Guidance 254 (UK HSE HSG 254) provides a methodology to develop process-specific leading and lagging metrics. Recommendation 4-4. Given that the two facilities are pilot facilities and make extensive use of first-of-a-kind equipment, the Pueblo Chemical Agent Destruction Pilot Plant and the Blue Grass Chemical Agent Destruction Pilot Plant should review their hazard assessment documents to identify and consider implementing leading or lagging metrics specific to each piece of equipment or area of the plant. These efforts should follow the approach outlined in the United Kingdom’s Health and Safety Executive Health and Safety Guidance 254 (UK HSE HSG 254), Developing Process Safety Indicators: A Step-by-Step Guide for Chemical and Major Hazard Industries. Finding 4-5. A formalized mechanism for a periodic review of process safety metrics by management is an established best practice in industry to verify that management is involved and can drive continuous improvement. Recommendation 4-5. The Program Manager for Assembled Chemical Weapons Alternatives and site management should perform periodic reviews of process safety metrics utilized at PCAPP and BGCAPP and implement action plans as appropriate to drive continuous improvements. Finding 4-6. The chemical and petroleum industries have found it very beneficial to have employees on staff with process safety expertise. These individuals partner with senior management and are accountable for monitoring industry best practices in process safety and for implementing those that are applicable within their facilities. These individuals are also tasked with assisting in embedding process safety into the organization’s culture by organizing and leading grassroots process safety teams while reviewing outcomes and metrics with management. Recommendation 4-6. The Program Manager for Assembled Chemical Weapons Alternatives should maintain process safety expertise at the programmatic level to ensure effective implementation of process safety metrics. To be successful, process safety experts must partner with and be supported by management. Finding 4-7. There are a number of resources that the Program Manager for Assembled Chemical Weapons Alternatives can use to learn about best practices for process safety management in the chemical and petroleum industries. Process safety technology conferences such as the American Institute of Chemical Engineers’ annual Global Congress of Process Safety and others hosted by organizations such as the Center for Chemical Process Safety and the Mary Kay O’Connor Process Safety Center provide ongoing programming on process safety and the identification of best practices. Recommendation 4-7. The Program Manager for Assembled Chemical Weapons Alternatives should undertake a review of best practices in process safety management, especially in the chemical and petroleum industries. These practices are described in the Center for Chemical Process Safety book Guidelines for Risk Based Process Safety. Those that are applicable should be incorporated into the Pueblo and Blue Grass Chemical Agent Destruction Pilot Plants.