National Safety Month

Free Case Study:

Large Winery Operation

For National Safety Month, enjoy this free case study from
Patty's Industrial Hygiene, 7th Edition extracted from the
chapter “Prevention Through Design” by Georgi Popov.
Case Study: Large Winery Operation
A large winery with an annual production capacity of over 1 million gallons of wine had
concerns regarding the use of liquified sulfur dioxide (SO2). Management was alarmed
when a minor release of pure liquified SO2 outside the facility sent an employee to the
urgent care facility. Fortunately, the release was small and occurred outdoors reducing the
severity of exposure.

Inhalation is the major route of exposure to sulfur dioxide. The odor threshold is five times
lower than the OSHA permissible exposure limit (PEL) (5 ppm). Sulfur dioxide exposures
can have both short-term and chronic health consequences for people with lung disease.
Inhaled sulfur dioxide readily reacts with the moisture of mucous membranes to form
sulfurous acid (H2SO3), which is a severe irritant (13). The reaction of SO2 and moisture is
presented below.

SO₂ + H₂O H₂SO₃

A second concern was discovered when a chemical dosing machine in the bottling line had
a minor release during a change out of the chemical dimethyl dicarbonate (DMDC). The
employees were evacuated without injury.

These two incidents led the winery to determine the level of risk and potential solutions. A
risk assessment team was formed, and an assessment was performed. The team
determined that the SO2 and DMDC exposure risks both presented multiple fatality – level
risk and required immediate risk treatment.

Management sets the expectations, context, and objectives of the assessment. The risk
assessment team was established that included the consultant as facilitator, the
winemaker, assistant winemaker, cellar manager, operations manager, bottling
department manager, maintenance manager, and Health and Safety Executive (HSE)
manager.

Data were collected regarding the SO2 and DMDC operations, equipment and instruments
used, instructions, chemicals, and their SDSs, operator training, procedures, and available
incident information. A search for similar events involving SO2 and DMDC were also
conducted. Employees were interviewed to learn from their experiences, concerns, and
suggestions.

The two procedures were observed to document and understand the sequence of tasks
and potential risks associated with tasks. Photographs, tank quantities, room dimensions
and configurations, distances to exits, means of egress, and other physical attributes were
collected.

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After reviewing the information, the potential concerns of fatalities or serious incidents
were discussed. Workplace exposures such as pure SO2 releases and DMDC releases
which present a potential for fatalities or serious incidents must be given the highest
priority and controlled to an acceptable level. As a side note, the consultant explained that
unlike like less-serious workplace incident rates, fatality, and serious incident/injury rates
have not declined and do require serious attention. FSI exposures that can result in
environmental releases, explosions, and disasters have been found to involve some of the
following factors (14):

• Unusual and nonroutine work

• Nonproduction tasks
• Facility modification or construction activities
• Shutdowns and startups for repair and maintenance tasks
• Exposure to high-energy sources (e.g. electrical, steam, pneumatic, chemical)
• Upsets (situations going from normal to abnormal).

Management agreed that the need to eliminate or reduce these FSI risk level exposure was
required. With management input, the risk assessment team established risk criteria to be
used for the assessment. As determined in the initial investigation, concerns were
identified by employees handling pure liquified sulfur dioxide in the dosing of wine tanks,
and in the use of the DMDC dosing machine. A simplified PHA method was used to help
identify hazards, analyze, and evaluate their risk levels, prioritize actions, and select
controls using the hierarchy of controls model (Figure 8). The primary concerns were the
use and storage of 100% liquified SO2 and DMDC.

Future risk
likelihood

likelihood
risk level
severity

severity
Current

Current

Current

Future

Future

level
Task Hazard Recommended controls

SO2 dosing Health risk from Substitute 100% SO2 with

using 100% leak or release; 2 6% SO2 and K2 S2 O5
SO2 liquid ppm PEL; 100 ppm effervescent tablets,
lethal dose; granular, powder
4 3 12 2 2 4
Heavier than air.
EPA regulated
product.

DMDC Health risk to Relocate DMDC unit outside

metering bottling employees building (connected with
equipment from leak or release hose) with open ventilation
in bottling in area; 0.4 ppm away from bottling area;
4 3 12 3 1 3
area exposure ceiling continue to follow safety
limit protocols and PPE for
operator.

FIGURE 8 Simplified PHA.

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Concern #1 – Sulfur Dioxide
SO 2 is used to protect wine from yeast and microbial growth, which can spoil or reduce
its quality. The winery purchased the 100% liquified SO 2 concentration thinking that it
was cheaper to purchase it in the pure form and would require less frequent
purchasing. SO 2 at 100% concentration presents several significant concerns,
including the safety and health of employees (risks include death and blindness) and
environmental reporting requirements. The Cal-OSHA PEL is 2 ppm, and the lethal
dose is 100 ppm. Sulfur dioxide gas is heavier than air (density 2.83 kgm–3) and can
accumulate in closed areas. The configuration and limited ventilation of the bottling
areas present a risk to employees, should a SO 2 release occur.

In addition, the quantity of 45 gallons, which weighs 548 lbs., exceeds the threshold
planning quantity (TPQ) of 500 lbs. for US Environmental Protection Agency (EPA)
SARA Title III Sections 302 and 304, Extremely Hazardous Substances. Potential FSI
scenario from a release of SO 2 in a 100% liquid concentration used to dose large tanks
outside and inside buildings during the winemaking process. The dosing process
required employee to dispense a small amount into a dosing instrument that attaches
to the bulk tank inside the building. Figure 9 shows the filling and dispensing process
equipment and tanks.

Concern #1 – Sulfur Dioxide

Used for dosing tanks inside
buildings
Filling and dispensing

FIGURE 9 Pure sulfur dioxide liquid filing and dispensing

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Concern #2 – Dimethyl Dicarbonate
O O
Dimethyl decarbonate,
H3C CH 3
O O O CASRN: 4525-33-1

DMDC is a microbial control agent used in place of filtering to prevent spoilage of wine.
Trained operators and special equipment are used to dose the wine in a closed system.
The location of the DMDC metering equipment (shown in Figure 10) in the bottling area
presented a potential exposure to bottling employees in the event of a release. The
bottling area had limited ventilation and limited means of escape.

Concern #2 – DMDC dosing

Dosing/metering equipment
located in the bottling area

Bottling area with limited

ventilation and limited means of
escape

Exposure ceiling limit is 0.04 ppm

Releases have occurred due to

operator error and equipment
failure

FIGURE 10 DMDC dosing machine in bottling area

In the event of a release of DMDC, the bottling crew would be vulnerable. Human studies
have shown that DMDC is a highly corrosive skin irritant and that dermal contact may
result in irreversible skin damage, scale formation, and necrosis. DMDC is known to cause
adverse effects on the respiratory system as well (15).

The SDS for DMDC indicates that its exposure ceiling limit is 0.04 ppm, a very small
quantity, which means any release can lead to severe exposure. In the “Safety Precautions
When Handling DMDC” from the manufacturer, it states that DMDC is toxic if inhaled and
should only be used in well-ventilated areas. In addition, the document warns that in the
event of a spill or release, personnel must be evacuated immediately. According to the
SDS, the odor of DMDC cannot be used as a warning against inhalation exposure, and that
“a NIOSH approved air-purifying organic vapor respirator must be used when
concentrations are between 0.04 and 10 ppm”; and “positive pressure air-supplied
respirators if concentrations are unknown or exceed 10 ppm or if the workspace is
confined and unventilated” (8).

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Risk Analysis
Using Tables 5 and 6 to estimate severity and likelihood levels, the two concerns were
analyzed. The risk assessment team reviewed available information and performed the
risk analysis using the PHA format shown in Figure 8. In the current state, both the SO2 and
DMDC risks were estimated to have a risk level of 12, an unacceptable risk level to the
organization. Both risks were estimated to have a severity level estimated at 4 or
“catastrophic” and a likelihood level of 3 or “very likely.” The PHA risk assessment tool
provides a comparison of the risk levels before and after recommended risk treatment
measures are implemented.

TABLE 5 Severity levels.

Severity level Definition
Catastrophic (4) Fatalities; damage to community, environment, and reputation
High (3) Permanent disability injury or illness; Multiple injury events
Moderate (2) Injury or illness requiring medical attention
Low (1) Minor injury or first aid incident

TABLE 6 Likelihood levels.

Likelyhood level Definition
Very likely (4) Will happen under right situations; has occurred multiple times
Likely (3) Likely to happen under right circumstances; has occurred in past
Possible (2) Can happen in certain situations
Unlikely (1) Unlikely to happen; remotely possible

Risk Evaluation
With the risk analysis performed, management evaluated the need for action for these two
risks. The management team determined that the risk levels for both concerns were
unacceptable to the organization, using Table 7 as its rating system.

TABLE 7 Risk Levels.

Low (1) Moderate (2) High (3) Catastrophic (4)

Very likely (4) 4 8 12 16

Likely (3) 3 6 9 12

Possible (2) 2 4 6 8

Unlikely (1) 1 2 3 4

Where: Dark gray indicates high risk; Light gray indicates serious risks; Gray indicates medium
risk; Light dark gray indicates low risk.

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Risk Treatment Options
Using the hierarchy of controls model, the assessment team and management reviewed
possible solutions. Recognizing that higher-level controls would be more effective and
reliable, management stated that higher-level controls should be strongly considered. It
should be noted that this PtD example is a redesign of an existing process, not a new
design.

For concern #1, a review of available substitutions for pure SO2 suggests lower
concentrations of SO2 (aqueous solution) and powdered, granular, and tablet forms of
potassium meta-bisulfite. Costs for existing chemicals and procedures were determined
and compared to the proposed solutions and their projected costs. It was determined
that the costs of substituting with the less hazardous forms of SO2 were about the same
as the cost of pure SO2, but other benefits of using the less hazardous products were the
elimination of potential releases of highly hazardous chemicals to the surrounding
community, improved employee morale and enhanced management goodwill, and
reduced compliance costs and efforts. For concern #2, the location of the DMDC
metering machine directly placed in the congested bottling area was evaluated.

It became apparent that the machine could be relocated away from the bottling area
with piping to the bottling system. Similar benefits such as employee health, improved
morale, management goodwill, and increased space were considered.

Risk Treatment Selected

For concern #1, the winery decided to replace (substitute) pure liquefied SO2 with
much less hazardous 6% SO2 solution and potassium meta-bisulfide tablets. For
concern #2, until the bottling line can be relocated to a more open area with good
ventilation, it was decided that the DMDC metering equipment should be removed
(eliminated) from inside the bottling room and relocated outside the building with
hard piping into the bottling room.

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Monitoring, Review,
and Benefits of Risk Treatments
Following the implementation of both risk treatments, the HSE manager performed
periodic monitoring of the new practices. No new hazards were introduced with the two
risk treatments. The results of implementing recommended higher-level controls
including substitution and elimination provided the following benefits to the
organization:

• A reduction in the risk level of 67% for SO2 exposure risk to employees
and surrounding community.

• A reduction in risk level of 75% for DMDC exposure risk.

• Improved employee morale.

• Eliminated EPA reporting requirements for SO2.

• Reasonably low costs for the potassium meta-bisulfite (K2S2O5)

effervescent tables and ease of use.

• Very little cost to relocate and shelter the DMDC metering machine outside
of the winery (relocated the system to the outside of the building to
eliminate the risk to employees in the bottling areas).

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THE BUSINESS CASE
When examined using concepts of a business case (which captures the reasoning for
initiating or continuing a project or task), PtD solutions have been shown to be good
business decisions, whether the analysis includes financial or nonfinancial measures. The
NIOSH Workplace Design Solution, “Supporting PtD Using Business Value Concepts”
discusses this and provides further references (16, 17).

To evaluate the benefits of the prevention control measures, a PtD business case tool was
developed.

The business case model estimates potential benefits of the improvements. For this
project, the risk treatments led to substantial risk reduction and had financial and other
nonfinancial benefits for the winery. Risk reduction is considered the most important
nonfinancial benefit. Legal issues, improvements in Process Cycle Efficiency, and employee
turnover rate before and after the interventions are presented in Figure 12. PtD
intervention outcomes are presented in Figure 12.

Outcome measures – financial

Net present value (NPV) $247 800.29
Internal rate of return (IRR) 34.80%
Return on investment 101.83%
Payback period (years) 2.04

Outcome measures – non-financial

OSH risk reduction 68.75%
Business risk reduction 62.96%
Legal issues Eliminates the need for EPA TQPQ reporting. U.S.
EPA SARA Title III, Sections 302 and 304
Process cycle efficiency Eliminated unpopular PPE leading to improved
production effectiveness
Employee turnover Fewer illnesses and better morale improved
employee retention

FIGURE 12 PtD intervention outcomes.

OSH professionals who participate in the design safety process and PtD efforts should take
credit for the benefits derived from a successful completed project. An organization’s value
creation and protection, as well as achievement of business objectives at an acceptable
risk level, improved quality and production, employee and stakeholder satisfaction, and
cost savings, are all ultimately derived from successful PtD efforts.

Bibliography
8. Lyon, B.K. and Popov, G. (2018). Risk Management Tools For Safety Professionals. Park Ridge, IL: American Society of Safety Professionals.

13. ATSDR (2020). Medical management guidelines for sulfur dioxide (SO2). https://www.atsdr.cdc.gov/MMG/MMG.asp?id=249&tid=46#:~:text=Rout
es%20of%20Exposure&text=Inhaled%20sulfur%20dioxide%20readily%20reacts,than%200.1%20ppm%20when%20exercising (accessed 1 September 2020).

14. Manuele, F.A. (2014). Advanced Safety Management: Focusing on Z10 and Serious Injury Prevention, 2e. Hoboken, NJ: Wiley.

15. NLM PubChem (2004). Bethesda (MD): National Library of Medicine (US), National Center for Biotechnology Information. PubChem Compound
Summary for CID 3086, Dimethyl dicarbonate. https://pubchem.ncbi.nlm.nih.gov/compound/Dimethyl-dicarbonate (accessed on September 2 2020).

16. NIOSH (2015). NIOSH workplace design solutions: supporting prevention through design (PtD) using business value concepts. In: Centers for
Disease Control and Prevention (ed. E. Biddle and S. Afanuh). Cincinnati, OH: U.S. Department of Health and Human Services, National Institute for
Occupational Safety and Health. DHHS (NIOSH) Publication No. 2015-198.

17. AIHA (2009). Strategy to Demonstrate the Value of Industrial Hygiene. Falls Church, VA: American Industrial Hygiene Association. 9