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CSB Investigation Report No. 2017-01-I-KS 2016 Safety Safety Environmental Environmental
MGPI Processing Toxic Chemical Release (Atchison)
MGPI Processing, Inc., Atchison, Kansas
Related equipment → piping (piping)
0Fatalities
120Injuries
FailureMechanism code FTS
Failure Mode · ISO 14224 Mapping
Damage mechanism (recorded in KB)
FailureFTS
ISO functional code (as recorded · corrected)
ISO 14224:2016 functional failure code
ELP · External leakage - process fluid
Original code FTS corrected to ISO ELP — External leakage - process fluid.
Original recorded code semantics mismatch · corrected to ELP
1What Happened

Delivery truck misconnected to incompatible-material tank -> exothermic reaction -> toxic vapor release (piping transfer/labeling deficiency)

2Root Cause

Deficient transfer-connection design + unclear pipe labeling + human error (Harcros truck misconnected to MGPI incompatible tank)

3Reliability Lessons (from investigation root cause)
  • Deficient transfer-connection design
  • unclear pipe labeling
  • human error (Harcros truck misconnected to MGPI incompatible tank)
4Associated Failure Mechanisms (Keywords)
piping unloading misconnection incompatible material reaction leak release labeling
About the Failure-Mode Code (click to expand)

The originally recorded code FTS is an ISO 14224 functional code but its semantics do not match the actual failure (see the Mapping block above); it has been corrected to ELP based on the accident narrative. ISO 14224 functional codes describe what the equipment failed to do; the damage mechanism (how it failed) is a different dimension.

5Evidence Source (transparent)
Authority:U.S. Chemical Safety and Hazard Investigation Board (CSB)
Official Report:www.csb.gov ↗
Data Verification:verified_url_csb_case_page_curl200
Report No. 2017-01-I-KS · Data from CSB public investigation conclusions, compiled by Reliability AI, for reliability demonstration purposes only. This case is derived from public incident investigation reports for learning purposes only. AIM does not endorse or guarantee its accuracy.