LoC: DISCHARGE

Just after 3:00 pm on Saturday, October 11, 2008, a tank located in a storage building at the INDSPEC Chemical Corporation (INDSPEC) resorcinol facility in Petrolia, Pennsylvania, overflowed during an oleum transfer. Oleum, a mixture of sulfuric acid and sulfur trioxide, filled the exhaust ventilation system (vent system) connected to the tank and eventually released into the storage building. The release of oleum created a cloud of sulfuric acid mist that filled the building and flowed out of the facility into the community.

As the oleum storage tank overflowed, the storage building filled with a dense mist, and liquid oleum spilled from the vent system. Faced with an uncontrolled release, the INDSPEC incident commander declared a plant-wide emergency, notified local fire departments, and requested mutual aid services. Facility personnel evacuated.

While INDSPEC emergency responders managed the onsite incident, at 5:14 pm community emergency responders ordered the evacuation or shelter-in-place of about 2,500 nearby residents from the towns of Petrolia, Bruin, and Fairview. The evacuation order continued until about 2:00 am.

KEY ISSUES:
• TEMPORARY CHANGE EVALUATION
• SAFEGUARD EVALUATION
• PROCESS HAZARD ANALYSIS

ROOT CAUSES:
1. The facility did not evaluate the significance of a change to the emergency power supply.
2. The facility gave operators only verbal instruction on the use of the emergency power supply.
3. The oleum transfer work practice was never recorded in written operating procedures.
4. PHA teams were unable to evaluate the consequences of emergency power supply use.

Image credit: CSB

On October 21, 2016, a chemical release occurred at the MGPI Processing plant in Atchison, Kansas. MGPI Processing produces distilled spirits and specialty wheat proteins and starches. The release occurred when a chemical delivery truck, owned and operated by Harcros Chemicals, was inadvertently connected to a tank containing incompatible material. The plume generated by the chemical reaction led to a shelter-in-place order for thousands of residents. At least 120 employees and members of the public sought medical attention.

KEY ISSUES:
• DESIGN OF CHEMICAL TRANSFER EQUIPMENT
• AUTOMATED & REMOTE EMERGENCY SHUT-OFFS
• PIPE MARKINGS
• CHEMICAL UNLOADING PROCEDURES
• HUMAN FACTORS
• EMERGENCY PLANNING

ROOT CAUSES:
1. Design of connections & markings.
2. Inadequate procedures & training

Image credit: CSB

On the night of October 23, 2009, a large explosion occurred at the Caribbean Petroleum Corporation (CAPECO) facility in Bayamon, Puerto Rico, during offloading of gasoline from a tanker ship, the Cape Bruny, to the CAPECO tank farm onshore. A 5-million gallon aboveground storage tank (AST) overflowed into a secondary containment dike. The gasoline spray aerosolized, forming a large vapor cloud, which ignited after reaching an ignition source in the wastewater treatment (WWT) area of the facility. The blast and fire from multiple secondary explosions resulted in significant damage to 17 of the 48 petroleum storage tanks and other equipment onsite and in neighborhoods and businesses offsite. The fires burned for almost 60 hours. Petroleum products leaked into the soil, nearby wetlands and navigable waterways in the surrounding area.

KEY ISSUES:
• TANK OVERFILL PREVENTION
• COMMUNITY IMPACT
• HAZARD ASSESSMENT
• SAFETY MANAGEMENT SYSTEM
• REGULATION GAPS: NO RISK ASSESSMENT CONSIDERING PROXIMITY TO COMMUNITIES
• REGULATION GAPS: NO ADHERENCE TO RAGAGEP
• REGULATION GAPS: NO REDUNDANT OR INDEPENDENT SAFEGUARDS TO PREVENT OVERFILLING A TANK

ROOT CAUSES:
1. Deficient Management System.
2. Production Pressure.
3. Lack of reliable instruments:Level control failure due to inaccurate available volume calculation.
4. No high-level alarm to notify ship to stop transfer or divert flow.
5. No AOPS with ability to shut down or divert flow into tank.

Image credit: CSB

On October 29, 2007, at about 1 p.m., a fire and series of explosions occurred at the Barton Solvents Des Moines, Iowa, chemical distribution facility. The initial fire started in the packaging area while a 300-gallon portable steel tank, known as a tote, was being filled with ethyl acetate, a flammable solvent.

An operator placed the fill nozzle in the fill opening on top of the tote and suspended a steel weight on the nozzle to keep it in place.1 After opening the valve to begin the filling process, the operator walked across the room to do other work. As the tote was filling, he heard a ‘popping’ sound and turned to see the tote engulfed in flames and the fill nozzle laying on the floor discharging ethyl acetate. Before evacuating, employees tried unsuccessfully to extinguish the fire with a handheld fire extinguisher. The fire spread rapidly to the wood-framed warehouse, igniting a large volume of flammable and combustible liquids.

One employee received minor injuries and one firefighter was treated for a heat-related illness. A large plume of smoke and rocketing barrels and debris triggered an evacuation of the businesses surrounding the facility. The main warehouse structure was destroyed and Barton’s business was significantly interrupted. .

KEY ISSUES:
• ENSURE THAT EQUIPMENT, SUCH AS FILL NOZZLES AND HOSES, IS BONDED & GROUNDED AND DESIGNED FOR FLAMMABLE SERVICE
• USE DIP PIPES WHEN TOP-FILLING PORTABLE TANKS
• INSTALL FIRE SUPPRESSION SYSTEMS IN FLAMMABLE PACKAGING AREAS
• SEPARATE FLAMMABLE PACKAGING AREAS FROM BULK STORAGE AREAS

ROOT CAUSES:
1. The fill nozzle and hose used at Barton were not designed to be bonded and grounded, and were not intended for flammable service.
2. A fire suppression system in the packaging area likely would have stopped the rapid spread of the fire to the warehouse.
3. Proper separation from the warehouse by fire-rated walls and doors would have helped prevent the fire from spreading to the warehouse.

Image credit: CSB

An explosion occurred in an air line in a reactor used for the liquid phase oxidation of butane as it was being started up. The explosion ruptured the external portion of the air line to the reactor, allowing the reactor contents to vaporize and form a cloud. The vapor cloud drifted and ignited about 25 to 30 seconds after the initial release. There was extensive property damage in the immediate area as a result of the vapor cloud explosion and significant damage throughout the site. Windows were broken seven miles away. The immediate cause was believed to be insufficient purging of the reactor when it had previously been down.

[ Property Damage $215 Million. Estimated Current Value $516 Million ]

Image credit: The Center For Land Use Interpretation

On November 15, 2014, approximately 24,000 pounds of highly toxic methyl mercaptan was released from an insecticide production unit (Lannate® Unit) at the E. I. du Pont de Nemours and Company (DuPont) chemical manufacturing facility in La Porte, Texas. The release killed three operators and a shift supervisor inside a manufacturing building. They died from a combination of asphyxia and acute exposure (by inhalation) to methyl mercaptan.

KEY ISSUES:
• EMERGENCY PLANNING & RESPONSE (PREPAREDNESS)
• IMPLEMENTATION OF PROCESS SAFETY MANAGEMENT SYSTEMS
• ASSESSMENT OF PROCESS SAFETY CULTURE

ROOT CAUSES:
1. DuPont’s corporate process safety management system did not ensure that DuPont La Porte implemented and maintained an effective process safety management system; and
2. DuPont La Porte did not assess its culture for process safety in the site’s Safety Perception Surveys or any other formal assessment program, allowing serious process safety deficiencies to exist at the site.

Image credit: CSB

On November 22, 2006, at about 2:45 am, a violent explosion at the CAI/Arnel manufacturing facility rocked the town of Danvers, MA. The explosion and subsequent fire destroyed the facility, heavily damaged dozens of nearby homes and businesses, and shattered windows as far away as two miles. At least 10 residents required hospital treatment for cuts and bruises. Twenty-four homes and six businesses were damaged beyond repair. Dozens of boats at the nearby marina were heavily damaged by blast overpressure and debris strikes.

The fire department ordered the evacuation of more than 300 residents within a half-mile radius of the facility. Numerous residents could not return for many months while they waited for their houses to be rebuilt or repaired. Seventeen months after the explosion, six homes had yet to be reoccupied as repairs were not complete..

KEY ISSUES:
• SAFE HANDLING OF FLAMMABLE LIQUIDS
• FIRE CODE COMPLIANCE & ENFORCEMENT
• STATE & LOCAL GOVERNMENT HAZARDOUS FACILITY LICENSING

ROOT CAUSES:
1. CAI management did not conduct a process hazards analysis or similar systematic review of processes involving hazardous materials.
2. CAI management did not use written procedures or checklists to facilitate safe process operations.

Image credit: CSB

On November 28, 2003, two cases of Legionnaire’s Disease were recorded, the first symptoms of which dated back to the beginning of November. The dates of outbreak of the pathology, which were then staggered over time, revealed two distinct waves of contamination with a total of 86 individuals contaminated, aged between 32 and 92 (of whom 18 died).

These cases all broke out within a radius of slightly over 10 km around the city of Lens. The DDASS (local Sanitary and Social Affairs Office) conducted environmental investigations at the homes of patients and within several facilities open to the public. At the request of the DRIRE (Regional Agency for the Environment, Research and Industry), all facilities operating cooling towers within the designated zone were asked to adopt measures to identify the eventual presence of legionella and clean their circuits. On October 15, the operator of a chemical installation specialised in alcohols and fatty acids extracted samples whose results revealed a concentration of legionella at a level of 730,000 CFU units/litre. Following a shock treatment using biocides, analyses 15 days later yielded a concentration of less than 100 CFU/litre. On November 20, another inspection announced that the level of 600,000 CFU/litre had been reached.

In light of these results, the chemical plant’s cooling towers were ordered to be shut down on November 29. As of December 3, the tower circuits were drained and cleaned. Operations resumed on December 22, and a prefectural decree was issued January 2, 2004 mandating the operator to halt all plant activity once again due to the appearance of a second epidemic wave. High pressure cleaning work could have induced the dispersion of a contaminated aerosol. At the same time, the Prefect commissioned the DRIRE Agency to extend its investigations, notably by inventorying all cooling towers within the neighbouring 53 towns and imposed the shutdown of several installations (automobile washing stations, food processing activities, refrigerated warehousing, etc.), causing layoffs to hundreds of workers for several days. Even though a similarity was detected between the strains extracted from 23 of the patients and those present in the suspected cooling tower at the petrochemical plant, other sources of contamination could not be ruled out. High legionella counts in the lagoons of this same plant necessitated turning off aerators on January 20. This site’s revenue loss would amount to several millions of Euros, corresponding to a production downtime of 14 weeks. A prefectural order authorising reactivation of the towers was issued on March 19, 2004, yet the plant would never operate again.

Image credit: TF1

In the early hours of 3 December 1984 a relief valve on a storage tank containing highly toxic methyl isocyanate (MIC) lifted. A cloud of MIC gas was released which drifted onto nearby housing.

Prior to this, at 23.00 hrs on 2 December, an operator noticed the pressure inside the storage tank to be higher than normal but not outside the working pressure of the tank. At the same time a MIC leak was reported near the vent gas scrubber (VGS). At 00.15hrs a MIC release in the process area was reported. The pressure inside the storage tank was rising rapidly so the operator went outside to the tank. Rumbling sounds were heard from the tank and a screeching noise from the safety valve. Radiated heat could also be felt from the tank.
Attempts were made to switch on the VGS but this was not in operational mode.

Approximately 2,000 people died within a short period and tens of thousands were injured, overwhelming the emergency services. This was further compounded by the fact that the hospitals were unaware as to which gas was involved or what its effects were. The exact numbers of dead and injured are uncertain, as people have continued to die of the effects over a period of years.

The severity of this accident makes it the worst recorded within the chemical industry.

KEY ISSUES:
• PLANT MODIFICATION / CHANGE PROCEDURES
• REACTION / PRODUCT TESTING
• DESIGN CODES – PLANT
• MAINTENANCE PROCEDURES
• EMERGENCY RESPONSE / SPILL CONTROL

Image Credit: No credit

The International Biosynthetics (IBIS) plant was, at the time of the accident, a wholly owned subsidiary of Shell UK Ltd. and employed some 250 people in the manufacture of fine chemicals.

The release occurred on the phosgene plant at 11:27 hours on 7 December 1991. The batch reaction involved the phosgenation of dimethyl aniline (DMA) in a toluene solution. The process involved the addition of 1 tonne of recycled toluene to the reactor, then as no more recycled toluene was available fresh toluene was to be added. Attempts were made to fill the reactor with 2 tonnes of fresh toluene. The flow indicator showed that the required amount of toluene had been added to the reactor, however a control valve between the pump and the vessel was closed and none of the toluene had been added. A level measurement was available for the vessel but as the process appeared to be proceeding normally this was not checked.

The next stage was to add 20 kg of phosgene to check if any water was present in the reactor. This would have resulted in a temperature rise of the solution. Because there was insufficient toluene in the vessel, the temperature indicator was not in the solution and therefore showed no temperature rise. As there appeared to be no water in the reactor, 0.8 tonnes of phosgene were then added to the vessel. After a shift changeover the next steps in the process were carried out. These were to add 1.6 tonnes of DMA and heat to 65°C. The operating temperature was reached but the temperature continued to rise to well above 100°C. As the pressure increased the pressure control valve, pressure relief valve and bursting disc all operated as designed and relieved the vessel to a scrubbing column. The reaction was more violent than had been predicted and the relief system had insufficient capacity to deal with the pressure rise. This resulted in a connection on the condenser line failing and releasing the contents of the vessel to atmosphere. Fortunately the phosgene had been consumed in the reaction. However, the vapour cloud drifted for 4 km affecting about 60 people and staining some property blue.

KEY ISSUES:
• CONTROL SYSTEMS
• REACTION / PRODUCT TESTING
• RELIEF SYSTEMS / VENT SYSTEMS

Report: https://www.icheme.org/media/13702/release-of-chemicals-from-international-biosynthetics-ltd.pdf

Image Credit: HSE

An explosion ripped through the New Cumberland A.L. Solutions titanium plant in West Virginia on December 9, 2010, fatally injuring three workers. The workers were processing titanium powder, which is highly flammable, at the time of the explosion.

KEY ISSUES:
• FEDERAL COMBUSTIBLE DUST OVERSIGHT
• HAZARD RECOGNITION & TRAINING
• LEARNING FROM PREVIOUS INCIDENTS

ROOT CAUSES:
1. AL Solutions did not mitigate the hazards of metal dust explosions through engineering controls, such as a dust collection system. Specifically, AL Solutions did not adhere to the practices recommended in NFPA 484 for controlling combustible metal dust hazards.

Image credit: CSB

In the early hours of Sunday 11th December 2005, a number of explosions occurred at Buncefield Oil Storage Depot, Hemel Hempstead, Hertfordshire. At least one of the initial explosions was of massive proportions and there was a large fire, which engulfed a high proportion of the site.

Over 40 people were injured; fortunately there were no fatalities. Significant damage occurred to both commercial and residential properties in the vicinity and a large area around the site was evacuated on emergency service advice. The fire burned for several days, destroying most of the site and emitting large clouds of black smoke into the atmosphere.

KEY ISSUES:
• SYSTEMATIC ASSESSMENT OF SAFETY INTEGRITY LEVEL REQUIREMENTS
• PROTECTING AGAINST LOSS OF PRIMARY CONTAINMENT
• ENGINEERING AGAINST ESCALATION OF LOSS OF PRIMARY CONTAINMENT
• ENGINEERING AGAINST THE LOSS OF SECONDARY AND TERTIARY CONTAINMENT
• OPERATING WITH HIGH RELIABILITY ORGANISATIONS
• DELIVERING HIGH PERFORMANCE THROUGH CULTURE AND LEADERSHIP

HSE Reports:
MIIB Final Report Vol 1: https://www.icheme.org/media/13707/buncefield-miib-final-report-volume-1.pdf
MIIB Final Report Vol 2a: https://www.icheme.org/media/13923/buncefield-miib-final-report-volume-2a.pdf
MIIB Final Report Vol 3a: https://www.icheme.org/media/13923/buncefield-miib-final-report-volume-2a.pdf
Land Use Planning – Recommendations: https://www.icheme.org/media/10694/recommendations-on-land-use-planning.pdf
Land Use Planning – Model: https://www.icheme.org/media/13709/illustrative-model-of-a-risk-based-lup-system_repaired.pdf
Explosion Mechanism: https://www.icheme.org/media/10696/buncefield-explosion-mechanism-advisory-group-report.pdf
BSTG Final Report: https://www.icheme.org/media/10697/safety-and-environmental-standards-for-fuel-storage-sites.pdf
Emergency Preparedness: https://www.icheme.org/media/10698/recommendations-on-emergency-preparedness.pdf
Design & Operation: https://www.icheme.org/media/10699/recommendations-on-the-design-and-operation-of-fuel-storage-sites.pdf
Initial Report: https://www.icheme.org/media/10700/buncefield-initial-report.pdf
Investigation – Progress Report: https://www.icheme.org/media/10705/buncefield-first-progress-report.pdf
Investigation – 2nd Progress Report: https://www.icheme.org/media/10703/buncefield-second-progress-report.pdf
Investigation – 3rd Progress Report: https://www.icheme.org/media/10702/buncefield-third-progress-report.pdf
Why did it happen?: https://www.icheme.org/media/10706/buncefield-report.pdf

Image Credit: Hertfordshire County Council

On 4th January 1966, an operation to drain off an aqueous layer from a propane storage sphere was attempted. Two valves were opened in series on the bottom of the sphere. When the operation was nearly complete, the upper valve was closed and then cracked open again. No flow came out of the cracked valve, so it was opened further. The blockage, assumed to be ice or hydrate, cleared and propane gushed out. The operator was unable to close the upper valve and by the time he attempted to close the lower valve this was also frozen open. The alarm was raised and traffic on the nearby motorway was stopped. The resulting vapour cloud is thought to have found its source of ignition from a car about 160 m away. The storage sphere was enveloped in a fierce fire and upon lifting of the relief valve a stream of escaping vapour was ignited.

The LPG tank farm where the sphere was located consisted of four 1200 m3 propane and four 2000 m3 butane spheres. The fire brigade arrived on site, but were not experienced in dealing in refinery fires, and it appears they did not attempt to cool the burning sphere. They concentrated their hoses on cooling the remaining spheres. About 90 minutes after the initial leakage, the sphere ruptured, killing the men nearby. A wave of liquid propane flowed over the compound wall and fragments of the ruptured sphere cut through the legs of the next sphere which toppled over. The relief valve on this tank began to emit liquid.

The fire killed 18 people and injured 81 others. Five of the storage spheres were destroyed.

KEY ISSUES:
• DESIGN CODES – PIPEWORK
• SECONDARY CONTAINMENT
• OPERATING PROCEDURES
• EMERGENCY RESPONSE / SPILL CONTROL
• DESIGN CODES – PLANT

Image Credit: Fonds Georges Vermard

An explosion occurred on this oil sands upgrader site north of Fort McMurray, Alberta. Five workers were injured in the blast, including one who received third-degree burns. A subsequent fire occurred at the top of one of the site’s four coke drums and burned for nearly four hours. As a result, two of the coke drums were disabled. Workers returned to normal shifts the following morning. The majority of the damage was sustained above the cutting deck and derrick infrastructure of the coke drum. At the time of the incident, the plant was operating on bypass conditions due to process upsets. An internal investigation team determined that the fire resulted from the opening of the top unheading valve on an active low-pressure coke drum. This allowed hot hydrocarbons to be released within the coker cutting deck building and was followed by ignition, leading to the explosion and fire. Exceptionally cold weather following the incident hampered efforts to gain access to the coker unit’s cutting deck, due to the deluge protection in this area. Firefighting in freezing conditions caused additional damage.

[ Property Damage $385 Million. Estimated Current Value $425 Million ]

Image credit: CBC

An explosion severely injured a graduate student at Texas Tech University in Lubbock, Texas, in the chemistry department during the handling of a high-energy metal compound, which suddenly detonated. Texas Tech had entered into an agreement with Northeastern University, which holds a contract from the U.S. Department of Homeland Security to study the high-energy materials.

KEY ISSUES:
• LABORATORY SAFETY MANAGEMENT FOR PHYSICAL HAZARDS
• HAZARD EVALUATION OF EXPERIMENTAL WORK IN RESEARCH LABORATORIES
• ORGANIZATIONAL ACCOUNTABILITY & OVERSIGHT OF SAFETY

Image & AcciMap Credit: CSB

On January 13, 2003, at approximately 4:30 pm, a vapor cloud deflagration and pool fire erupted at the BLSR Operating, Ltd. (BLSR), facility located 5 miles north of Rosharon, Texas. Two BLSR employees were killed, and three were seriously burned. Two T&L Environmental Services, Inc. (T&L), truck drivers, who had just delivered gas condensate storage tank basic sediment and water (BS&W) to BLSR, were seriously burned; one of these men died on March 2.

The fire was caused by the release of hydrocarbon vapor during the unloading of BS&W from two vacuum trucks into an open area collection pit. BS&W is an oil/gas exploration and production (E&P) waste liquid. The fire destroyed two 50-barrel (2,100-gallon) vacuum trucks and seriously damaged waste liquid offloading equipment and structures at BLSR. One of the vacuum truck diesel engines was the most likely source of ignition..

KEY ISSUES:
• RECOGNIZING FLAMMABILITY HAZARDS OF EXPLORATION & PRODUCTION WASTE LIQUIDS
• SAFE HANDLING OF FLAMMABLE LIQUIDS

ROOT CAUSES:
1. Noble Energy, Inc., the shipper, failed to identify the flammability hazard of BS&W generated at its gas well production facility, and also failed to communicate the hazard to employees and contractors who were required to handle the flammable liquid.
2. T&L management did not require Noble Energy to provide vacuum truck drivers with a material safety data sheet or other document listing the potential flammability hazard of BS&W, nor did it identify the flammability hazard of the mixture in the vacuum truck tank.
3. BLSR management did not have effective hazard communication practices in place to recognize the potential flammability hazard of each shipment of BS&W, nor did it implement safe handling practices when offloading flammable liquid onto the mud disposal and washout pad area.

Image Credit: CSB

The incident occurred when workers were weighing a barrel of 4-hydroxybenzohydrazide. There was a short circuiting in the weighing scale which led to an explosion.

Proximate causes:
• Defective equipment

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Survival Technologies

During the early morning hours of January 25, ASCO employees filled cylinders with purchased acetylene. At approximately 9:30 am, with the depletion of the supply of purchased acetylene, they began to produce acetylene from calcium carbide in the generator.

Because of heavy snowfall, workers were shoveling snow in the area south of the decant tanks near the loading dock. At 10:36 am, an explosion occurred, centered in the shed. Two of the workers immediately south of the shed were killed instantly. A third worker farther south, closer to the loading dock, was severely injured and was pronounced dead shortly after arriving at the Newark Medical Center. A fourth worker who was in the loading dock/lime pit area was very seriously injured by the blast. .

KEY ISSUES:
• OPERATING PROCEDURES
• STAFF TRAINING
• DRAIN & VENT TO SAFE LOCATION
• BUILDINGS TO BE DESIGNED FOR ACETYLENE CONTAINMENT
• MECHANICAL INTEGRITY
• POSITIVE ISOLATION

ROOT CAUSES:
1. At ASCO, a line that could potentially contain acetylene drained into an enclosed wooden shed.
2. The shed in this incident was not designed or constructed in accordance with NFPA 51A.
3. At ASCO the check valve was relied upon to prevent backflow. The check valve and block valve that failed at ASCO and allowed backflow were not on a testing or inspection schedule. The single block valve on the recycle water line, which was found closed after the explosion, leaked during post-incident testing.
4. Operators did not use either written operating procedures or check lists for start up of the acetylene generator or recycled water system at this facility.

Image Credit: CSB

On January 29, 2003, an explosion and fire destroyed the West Pharmaceutical Services plant in Kinston, North Carolina, causing six deaths, dozens of injuries, and hundreds of job losses. The facility produced rubber stoppers and other products for medical use. The fuel for the explosion was a fine plastic powder, which accumulated above a suspended ceiling over a manufacturing area at the plant and ignited.

KEY ISSUES:
• HAZARD RECOGNITION & COMMUNICATION
• GOOD ENGINEERING PRACTICE
• LOCAL AMENDMENTS TO FIRE CODES

ROOT CAUSES:
1. West did not perform adequate engineering assessment of the use of powdered zinc stearate and polyethylene as antitack agents in the rubber batchoff process.
2. West engineering management systems did not ensure that relevant industrial fire safety standards were consulted.
3. West management systems for reviewing material safety data sheets did not identify combustible dust hazards.
4. The Kinston plant’s hazard communication program did not identify combustible dust hazards or make the workforce aware of such.

Image Credit: CSB

Three combustible dust incidents over a six month period occurred at the Hoeganaes facility in Gallatin, TN, resulting in fatal injuries to five workers. The facility produces powdered iron and is located about twenty miles outside of Nashville.

KEY ISSUES:
• HAZARD RECOGNITION AND TRAINING
• ENGINEERING CONTROLS
• FIRE CODES/ENFORCEMENT
• REGULATORY OVERSIGHT

ROOT CAUSES:
1. Hoeganaes facility management were aware of the iron powder combustibility hazard two years prior to the fatal flash fire incidents but did not take necessary action to mitigate the hazard through engineering controls and housekeeping.
2. Hoeganaes did not institute procedures – such as combustible gas monitoring – or training for employees to avoid flammable gas fires and explosions

Image credit: CSB