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16859 Chemical accident in USA with benzine (gasoline) unleaded
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General accident information
Class/Quality * * * * *
Year 1998
Summary Truck driver was transferring
Gasoline when tank overflowed
Due to low attention of driver
Causing fire and 6 casualties
Country USA
Activity TRANSSHIPMENT
Location FUELSTATION
Chemicals Benzine (gasoline) unleaded, Benzine (gasoline) unleaded, Benzine (gasoline) unleaded
Cause Human-failure
Fatalities/Injuries 5 / 2
Occurrences or events Block-of-system, Damage, Defective-working, Drive,
Drive, Evacuation, Fire, Fire fighting/Emergency response,
Human-operations, Human-operations, Human-operations, Human-operations,
Human-operations, Human-operations, Ignition, Load/Stow,
Management-failure, Management-failure, Management-failure, Management-failure,
Mount/Connect, No-action, No-action, No-action,
No-action, No-action, No-action, Overflow,
Overpressure, Pollution/Contamination, Release, Unload,
Wrong-action, Wrong-action, Wrong-action, Wrong-position
 
 
Full accident information 
download accident report Click here to view a document containing the full accident information

Country: UNITED STATES OF AMERICA (USA)
Date : 1998 0809


About 0053 hours, a truck-driver was transferring gasoline from a cargo tank to underground tanks at a gasoline station-convenience store, when an underground storage tank containing gasoline overflowed. An estimated 2.1/m3 of gasoline flowed from the storage tank, across the station lot into an adjacent highway, through an intersection, and into a storm drain.
The gasoline ignited under a passenger vehicle, and fire engulfed three vehicles near the intersection. Each of the three vehicles had two occupants. Of the six people five sustained fatal injuries and one received serious injuries. Additionally, a firefighter dispatched to the accident site sustained minor injuries while attempting to suppress the fire.
Damages were estimated at 55000 USA dollars.
Shortly after 1730 hours on August 8, a truck-driver, in accordance with the company's operating practices, telephoned the weekend dispatcher to obtain the assigned deliveries for his evening shift. The safety director, who was serving as dispatcher, told the truck-driver the delivery locations and the type and amount of gasoline to be delivered that evening. He told the driver to make deliveries to the following stations: Nos. 742, 743 and 736.
The driver's notes indicated that he wrote down the following station numbers: 742, 743 and 741. The driver did not, nor was he required by written company procedures to, repeat or read back the information to the dispatcher to verify its accuracy during the telephone call.
The truck-driver departed the city about 2100 hours and drove his tractor cargo tank trailer combination about 112/km to a refinery, where he arrived about 2208 hours. He loaded one of the cargo tank's four compartments with 9.4/m3 of premium unleaded gasoline and the other compartments with a total of 22.3/m3 of regular unleaded gasoline. He left the refinery at 2223 hours.
Arriving at the station No. 741 about midnight, the truck-driver parked the tractor cargo tank combination next to the remote fill ports. Company's operating practices require its drivers to present the bill of loading to the station operator before making the gasoline transfer. The truck-driver, however, did not do this. Drivers are also require to determine and document the gasoline level in an underground storage tank by inserting a graduated measuring stick that they carry on the cargo tank truck into the direct fill ports before and after transferring gasoline. This procedure, which drivers refer to as "sticking the tank," provides drivers with a product-level reading in inches.
According to the truck-driver, he was able to stick the premium unleaded tank, but access to the regular unleaded direct fill port initially was blocked by a parked vehicle. He therefore went into the convenience store to obtain an inventory printout from the on-site system Red Jacket terminal. He said that he did not know how to use the Red Jacket system so he asked for help from an employee. The store's assistant manager then generated a printout for him. Although the Red Jacket printout showed the liters of gasoline and ullage in each of the underground storage tanks, the driver did not fully understand the printout and that he had obtained it only for the inch reading that he was required to record on his paperwork.
The truck-driver, upon exiting the store, discovered that the vehicle blocking the direct fill port had moved. He was then able to stick the regular unleaded tank for his reading. He did not use the inch readings to calculate the available space in the underground storage tanks. Instead, he relied solely on the information he had obtained earlier from the company dispatcher. After taking the inch readings, he did not replace the lids on the direct fill ports.
The truck-driver took the inch reading before he began to transferring gasoline, that he hooked up the unloading hoses for both the premium and regular gasoline at the same time, and that he began unloading regular and premium simultaneously.
Station No. 741's video surveillance system tape shows the truck-driver entering the station at 0004 hours, walking to and from the restroom corridor, and then leaving at 0005 hours. The video tape shows the truck-driver reentering the store at 0011 hours, walking past the checkout counter, and then leaving the store at 0018 hours.
Once at the station, the driver made a number of operating errors. He did not determine the quantity of gasoline in the underground storage tanks, and he did not calculate the amount of gasoline that could safely be transferred from the cargo tank to the station storage tanks. After sticking the underground storage tanks through the direct fill ports, he failed to use the measurement that he obtained to calculate the available space for gasoline in the storage tanks.
He then failed to close the lids of the direct fill ports before beginning the gasoline transfer through the remote fill ports. Having both the remote and the direct port fill lids open rendered the tank system's pressure-controlled safety device ineffective and resulted in gas overflowing the direct fill port of the regular unleaded gasoline storage tank. Finally, the truck-driver did not properly monitor the gasoline transfer.
The truck driver transferred the cargo compartment of premium unleaded gas and two of the three compartments of regular unleaded gas into the underground storage tanks without incident. During the transfer from the cargo tank's third compartment into the regular unleaded underground storage tank, a customer witnessed gasoline flowing from the direct fill port on the east side of the station property. The customer described the gasoline stream as "several meters wide" and said that it "should have been visible to the truck-driver." The customer said that the truck-driver appeared to be "gazing" beyond the overflow "toward the casinos on the highway." The customer told the truck-driver that gasoline was overflowing.
The truck-driver then responded, "Okay, thanks," and closed a valve on the cargo tank to stop the flow.
When the customer returned from the convenience store to his car, he saw the truck-driver looking down at the transfer hoses. The truck-driver then climbed the ladder on the rear of the cargo tank, walked forward along the top of the tank, opened the manhole cover, and looked down inside the tank.
The driver stated that after he was approached by the customer, he shut off the flow of regular unleaded gasoline from the cargo tank, walked to the open direct fill port to make sure it was no longer overflowing and then climbed on top of the tank to assess the amount of gasoline remaining inside the cargo tank.
About 2.1/m3 of regular unleaded gasoline overfilled the underground storage tank. The excess gasoline flowed south from the open fill port through the gas station parking lot, then west along the north side of the highway across the intersection, where it entered a storm drain under the highway. The drain emptied into an open concrete culvert, which ran southward toward the Gulf of Mexico.
At the time of the overfill, three passenger vehicles, each of which had two occupants, were near the highway-drive intersection. Two sedans were waiting in line to turn onto the highway, while an eastbound pickup truck was turning onto the drive. Police department???s reports indicate that witnesses observed a fire ignited under one of the cars and engulfed all three vehicles. The fire ultimately caused the fatal injuries of five occupants and the serious injury of one occupant. The fire, following the fuel flow, spread to the open fill port lid in the station and through the storm drain.
About 0053 hours, a police officer on routine motor patrol on the highway observed a large fire consume an automobile at the intersection of the highway and the drive. The police officer radioed for assistance, and additional officers arrived within the next 10/minutes. The police evacuated a total of 80 people from the area, including the customers and staff from a restaurant at a boulevard, a hotel and the station No. 741.
At 0053 hours, a caller notified the 911 operator that a person was on fire at the gas station. At 0054 hours, a fire engine company was dispatched to the accident site, where it arrived about 0059 hours. In response to a second alarm at 0056 hours, two engines, an aerial truck, and supervisory personnel were dispatched to the scene, arriving between 0100 hours and 0103 hours. Responders established a command post on the highway, east of the fire scene. Fire units used about 190/l of foam and engaged in fire suppression and rescue operations until 0140 hours, when the fire was extinguished.
Five of the six occupants of the vehicles died as a result of the fire. The Hyunday sedan operator, a 25-year-old male, sustained serious injuries and survived. The Mazda sedan passenger, a 20-year-old female, and the Ford pickup truck passenger, a 56-year-old female, died at the accident scene.
The Hyunday passenger, an 18-year-old male, the Mazda operator, a 43-year-old female, and the Ford operator, a 58-year-old male, died from their injuries after being admitted to area hospitals. A firefighter who received minor injuries was treated and released from a local hospital.
The convenience store, adjacent landscaping, restaurant signs, and cargo tank truck (tankvehicle) sustained minor thermal damage. Estimated damages totaled about 55000 USA dollars and included the value of the three destroyed passenger vehicles and the costs of repairing the truck tractor, of repairing and testing the cargo tank, and of reopening the station No. 741.
At the time of the accident, the station No. 741 was 1 of 55 gas station convenience stores. The station has three underground storage tanks, each with a capacity of 45.5/m3.
At most stations, each underground storage tank has one fill port through which gasoline is transferred. At four sites, however, each underground storage tanks has two fill ports; one is a direct fill port, and the other is a remote fill port. Those sites are station No. 741 and other stations.
According to company officials and driver, using the remote fill ports at station No.741 for gasoline transfers affords drivers greater safety.
Drivers said that they preferred to use the remote fill port at station No. 741 because doing so enabled them to drive forward to exit the site. If they use the direct fill port, they have to exit the station by backing onto the highway.
Federal regulations require that underground storage tanks be equipped with safeguards to prevent spilling and overfilling during gasoline transfer.
The station company elected to install float valves in the tank vents of the station storage tanks. The float valve rises as gasoline fills the tanks, eventually seating against the end of the vent pipe and restricting the vapour flow through the vent pipe, which causes pressure to build. The pressure in the tank works against the head of the liquid in the cargo tank and the transfer hoses, causing a reduction in the flow of gasoline.
Because the operation of a float valve is pressure controlled, at a station having both direct and remote fill ports, such as station No. 741, only one fill port should be open during a gasoline transfer. If a second fill port is open, the vapour can escape through it, rendering the float valve safety feature ineffective.
Several weeks before the fire, the truck-driver overfilled an underground storage tank at another station. On this occasion, the truck-driver made the delivery to the correct facility. Like station No.741, this station has both direct and remote fill ports, although they are much closer together.
The incident occurred during the day, and the driver noticed the overfill after a small amount of gasoline (about 19-38/l) overfilled. The truck-driver contacted the company's office; and the operations manager, who was not aware that the station had remote fill ports, instructed him to climb on top of the cargo tank and determine how much of the load remained by looking into the cargo tank compartment. The operations manager directed the truck-driver to gauge all the receiving tanks and unload the rest of the gasoline into the premium unleaded underground storage tank. The owner of the facility maintained no records of the overfill at the station.
On July 15, 1996, a different truck-driver was involved in an overfill of about 190-230/l at the station No.741. That truck-driver then was transferring gasoline through the remote fill ports when it began to overfill through the direct fill ports, which he had left open after gauging the underground storage tanks. This truck-driver was not aware of any company document explaining transfers at facilities with remote fill ports.
The truckdriver's personnel file shows that, from May 5 to July 9, 1998, company officials noted 20/hours-of-service violations, including 15 70/hours violations, 3 10/hours violations, and 2 15/hours violations.
According to the company's safety director, the company issued the truck-driver three letters of reprimand for his violations.
The truck-driver was not fatigued on the morning on the fire. He had arranged with the company to work the night shift. He normally slept about 6/hours during the day, left for work about 2100 hours, and arrived back home between 0800 hours and 0900 hours. His "Driver's Daily Log" indicates that on August 5 to 7, he went on duty at 2245 hours, 2300 hours, and 1915 hours, respectively. On August 8, he went to bed at 1130 hours and awoke at 1730 hours, at which time he called the dispatcher. His shift that evening began at 2100 hours.
Soon after the fire erupted, the truck-driver notified the company safety director, who immediately drove to the accident scene, a distance of about 272/km. The safety director later stated that he maintained a telephone list of agencies to contact in the event of an emergency and that he made several unsuccessful attempts to report the accident to the NRC while he was at the accident scene throughout the day. He then drove back to his home, where he fell asleep. When he awoke about 2100 hours, he remembered that he had been unsuccessful in reporting the accident and again tried to telephone the NRC with no success. He said that he then left his residence and drove to the company headquarters to check the phone number. At the office, he discovered that the number he had been using was incorrect, whereupon he called the NRC, which recorded the notification at 0022 hours, about 23/hours after the accident occurred.

Findings
1.
The company truck-driver was not impaired by drugs, alcohol, or fatigue on the morning of the accident.
2.
The physicians who performed the truck-driver's U.S. Department of Transportation physical could not adequately evaluate the truck-driver's medical fitness because he did not report background information related to his neurological condition.
3.
Although a significant factor in the company's hiring the truck-driver was his military background, the safety director did not attempt to check or to request the driver's military records, which contained useful information for determining his medical fitness and ability to operate heavy equipment.
4.
Because the truck-driver failed to report on his job application his employment with a carrier that had dismissed him, useful information from that carrier was not available to the company, to help company officials evaluate the truck-driver's ability perform his duties.
5.
The company's safety director failed to adhere to company procedures for hiring and training the truck-driver and for disciplining him when he failed to comply with the hours-of-service requirements.
6.
The company's operating manuals for its new employees and its driver-trainers lacked the specificity that employees need to ensure that they practice correct and safe cargo unloading procedures.
7.
To help drivers follow safe loading and unloading procedures, Federal regulations should require carriers that transport hazardous materials in cargo tanks to have specific written procedures for loading and unloading.
8.
Company's lack of adequate procedures for verifying the accuracy of dispatch orders resulted in the truck-driver delivering gasoline to the wrong location.
9.
Company employees lacked adequate procedures and training to prevent overfills of the underground storage tanks. The owners of the facility did not require its employees either to determine whether the amount of gasoline intended for delivery would fit in the underground storage tanks or to monitor alarms warning that the tanks were nearing maximum fill levels during cargo transfers.
10.
The EPA's program for preventing underground storage tank releases has not adequately addressed the requirements for preventing overfills of the type that occurred in the August 9, 1998.
11.
The effectiveness of requirements for telephonic notification of certain hazardous materials accidents would be strengthened if the requirements contained a specified time frame.

Probable cause
The NTSB determines that the probable cause of the accident was the failure of the company's officials to follow established company procedures in hiring and training new drivers, the company's lack of adequate procedures for dispatching driver and delivering cargo to customer facilities, and the failure of the owners of the facility, to have adequate safe procedures for accepting product offered for delivery at its stations. Contributing to the accident was the truck-driver's various and numerous operating errors during the gasoline transfer process that led to the underground storage tank overfill.

Lesson learned (recommendations)
As a result of its investigation, the NTSB makes the following safety recommendations:
To the Research and Special Programs Administration:
1.
Promulgate regulations requiring motor carriers that transport hazardous materials in cargo tanks to develop and maintain specific written cargo loading and unloading procedures for their drivers.
2.
Require that a hazardous materials incident meeting immediate notification requirements be reported within a specified time period to Federal authorities.
To the Federal Highway Administration:
1.
Once the Federal regulations requiring motor carriers that transport hazardous materials in cargo tanks to provide written cargo loading and unloading procedures are promulgated, ensure that the motor carriers are in compliance with the regulations.
To the Environmental Protection Agency:
1.
Taken action necessary to improve compliance which requires that owners and operators of underground storage tanks prevent their overfilling.
To the station company:
1.
Revise the driver and driver-trainer manuals to include specific written instructions on loading and unloading cargo and on the use of tools, such as storage tank capacity charts, necessary to deliver gasoline safely.
2.
Establish procedures to ensure that company officials adhere to written policies relating to hiring, and discipline of company truck-drivers.
To the transport company:
1.
Establish procedures and provide training to ensure that the employees verify that underground storage tanks have sufficient capacity for the gasoline or other petroleum products offered for delivery and monitor such transfers so that overfills do not occur.
To the National Association of Convenience Stores, the National Association of Truck Stop Operators, the Petroleum Marketers of America, the Service Station Dealers of America, and the Society of Independent Gasoline Marketers of America:
1.
Inform the members of the facts and circumstances of the accident and urge them to review their procedures and, if necessary, to revise them to require that station employees verify that underground storage tanks have sufficient capacity for gasoline or other petroleum products offered for delivery and to monitor such transfers so that overfills do not occur.
To the National Tank Truck Carriers Association:
1.
The members of the facts and circumstances of the accident and urge them to review the adequacy of their procedures for hiring and training truck-drivers and their written procedures for loading and unloading hazardous materials.
To the American Petroleum Institute:
1.
Inform the members having cargo tank motor carrier operations of the facts and circumstances of the accident and urge them to review the adequacy of their procedures for hiring and training truck-drivers and their written procedures for loading and unloading hazardous materials.




 
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