From: Alan Hall <oldeddoc**At_Symbol_Here**GMAIL.COM>
Subject: Re: [DCHAS-L] CSB Releases Update and Animation Detailing the Explosion and Fire at the PES Refinery in Philadelphia, PA
Date: Wed, 16 Oct 2019 11:49:33 -0500
Reply-To: ACS Division of Chemical Health and Safety <DCHAS-L**At_Symbol_Here**PRINCETON.EDU>
Message-ID: CALDugaY=AR1Pj6vBmwY+CYdzbBYNRRqCjCzKC0m-RyUc12xeMw**At_Symbol_Here**mail.gmail.com
In-Reply-To <579391544.3518218.1571242204419**At_Symbol_Here**mail.yahoo.com>


Monona, my Worthy Adversity (Everyone needs a Worthy Adversary to keep them in check),

We have the same goals, just different ideas about how to achieve them.

Ammonium biflouride is very toxic. It used to be marketed as a disinfectant for fish tanks. A kid whose case I consulted on drank the entire undiluted product, and despite all our efforts died. Calcium gluconate is not a bad treatment for HF dermal exposures, but there's a much better option (not currently available in the US, but in at least 40 other countries). Offline, I'd be happy to talk/type to anyone interested, but not on this listserve.

Alan
Alan H. Hall, M.D.
Medical Toxicologist
OldEDDoc**At_Symbol_Here**gmail.com
1-817-919-2308



On Wed, Oct 16, 2019 at 11:33 AM Monona Rossol <0000030664c37427-dmarc-request**At_Symbol_Here**lists.princeton.edu> wrote:
Such a big accident. But I'm writing up yet another HF death for my newsletter and thought it might be interesting to slide down frm 5000 pounds to less than three ounces of a compound that delivers HF on dermal or oral exposure. I'll quote two sections from a longer article in the Journal of Occupational and Environmental Medicine: September 2019 - Volume 61 - Issue 9 - p e394-e395 titled: "What Should OEM Physicians Know About Ammonium Bifluoride?"

CASE PRESENTATION
A healthy 12-month-old, 9.5 kg, girl played near a table while her mother worked on a glass etching art project. A 3-ounce bottle of consumer Armor Etch (Armour Products, Hawthorne, New Jersey) glass etching cream containing 40% to 70% AB [ammonium bifluoride] fell from the table and spilled on the child's walker tray. Moments later, the mother found the child splashing her hands in the etching cream and touching her mouth. The mother immediately dialed 911. The emergency dispatcher connected to poison control where realization of a potentially life-threatening ingestion prompted dispatch of helicopter transport to the home in order to speed the child directly to a tertiary care pediatric emergency department (ED). The child was believed to have arrived to a pediatric ED within 30 minutes of exposure. She arrived tachycardic, but with otherwise normal vitals, and was noted to be crying but otherwise acting age appropriate. She subsequently received external decontamination with soap and water, oral calcium carbonate, and a topical calcium solution. A mildly depressed ionized calcium level of 0.96 mmol/L (normal range 1.16 to 1.32 mmol/L) was noted, and the patient was started on a calcium gluconate 1 g IV (90 mg elemental calcium, approximately 9 mg/kg dose) infusion. Approximately 3 hours postexposure, and with little warning, the child decompensated into cardiac arrest with torsades de pointes. Pediatric advanced life support (PALS) protocol was initiated, and multiple doses of epinephrine, magnesium sulfate, and calcium gluconate were administered. Despite multiple attempts at defibrillation over 40 minutes, resuscitation efforts were unsuccessful. The child expired approximately 4 hours postexposure.

The article then lists other similar cases and concludes:

CONCLUSION
Exposure to AB-containing products can result in clinical toxicity that is virtually the same as that of HF. Severe systemic toxicity may result in severe hypocalcemia, ventricular dysrhythmias, or death, even with seemingly minimal amounts of oral and dermal exposure. The apparent misunderstanding that AB is safer than HF may lead to delays in recognition of toxicity and treatment.

I see this product and other almost identical products in art schools regularly. The faculty and students have no idea how toxic it is. There is no calcium gluconate in the place or anyone who would have a clue about what to do with it. Monona

-----Original Message-----
From: DCHAS Membership Chair <membership**At_Symbol_Here**DCHAS.ORG>
To: DCHAS-L <DCHAS-L**At_Symbol_Here**PRINCETON.EDU>
Sent: Wed, Oct 16, 2019 11:48 am
Subject: [DCHAS-L] CSB Releases Update and Animation Detailing the Explosion and Fire at the PES Refinery in Philadelphia, PA

To view this message in a browser, please click here: http://www.idevmail.net/message.aspx?d=86&m=2029

Chemical Safety Board Releases Factual Update and New Animation Detailing the Events of the Massive Explosion and Fire at the PES Refinery in Philadelphia, PA

Philadelphia, PA, October 16, 2019 - Today, the US Chemical Safety Board (CSB) released a factual update into the June 21, 2019, explosion and fire at the Philadelphia Energy Solutions (PES) Refinery in Philadelphia. The factual update notes that a pipe elbow, which had corroded to about half the thickness of a credit card, appears to have ruptured in the refinery's alkylation unit, releasing process fluid that included over 5,000 pounds of hydrofluoric acid, or HF. The leaking process fluid formed a large ground-hugging vapor cloud. Two minutes later, the cloud ignited, causing a massive fire and explosions.

Interim Executive Dr.. Kristen Kulinowski said, "Since 2015, the CSB has investigated three major incidents at refineries that utilize HF for alkylation. Incidents in Superior, WI, and Torrance, CA, fortunately did not result in an HF release. That was not the case here in Philadelphia. Though the main tank holding HF was not breached, HF was a component of the process fluid released from the alkylation unit. We are lucky there were no serious injuries or fatalities."

While the CSB's investigation is still ongoing, the factual update notes important details of the incident collected through interviewing witnesses, gathering evidence and ultimately, piecing together the events that led to the explosion:

- The piping was susceptible to corrosion from the hydrofluoric acid that was in the process fluid. The elbow that ruptured corroded faster than the rest of the piping in this part of the process.

- While pipe thickness in this section of the unit was periodically measured to monitor corrosion rates, the thickness of the elbow that failed had not been monitored for corrosion. The piece of piping that failed had a high nickel and copper content. Various industry publications have found that carbon steel with a higher percentage of nickel and copper corrodes at a faster rate than carbon steel with a lower percentage when used in a process with hydrofluoric acid.

- A secondary event at the PES refinery occurred when the V-1 Treater Feed Surge Drum ruptured , which launched a fragment of the vessel weighing 38,000 pounds across the Schuylkill River. Two other large fragments landed within the PES Refinery.

CSB Supervisory Investigator Lauren Grim said, "Corrosion is not a new issue for the CSB. In its prior investigation of a 2012 Chevron Refinery fire we determined that corrosion caused the rupture of a piping component. Similarly, the 2009 Silver Eagle refinery fire was also caused by the failure of piping that had thinned due to corrosion."

The CSB's interim animation details the events which occurred at the PES refinery on June 21 st , view the full animation at
http://www.idevmail.net/message.aspx?d=86&m=2029

During the news conference Interim Executive Kulinowski noted that moving forward the CSB is examining the need for more robust reviews of corrosion mechanisms as well as looking more closely at the use of HF in the refining process.

The CSB is an independent, non-regulatory federal agency whose mission is to drive chemical safety change through independent investigations to protect people and the environment. The agency's board members are appointed by the President and confirmed by the Senate. CSB investigations look into all aspects of chemical incidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems. For more information, contact public**At_Symbol_Here**csb.gov.

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