Contributory Factors: Housekeeping

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.

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On February 7, 2008, at about 7:15 p.m., a series of sugar dust explosions at the Imperial Sugar manufacturing facility in Port Wentworth, Georgia, resulted in 14 worker fatalities. Eight workers died at the scene and six others eventually succumbed to their injuries at the Joseph M. Still Burn Center in Augusta, Georgia. Thirty six workers were treated for serious burns and injuries – some caused permanent, life altering conditions. The explosions and subsequent fires destroyed the sugar packing buildings, palletizer room, and silos, and severely damaged the bulk train car loading area and parts of the sugar refining process areas.

KEY ISSUES:
• COMBUSTIBLE DUST HAZARD RECOGNITION
• MINIMIZING COMBUSTIBLE DUST ACCUMULATION IN THE WORKPLACE
• EQUIPMENT DESIGN & MAINTENANCE

ROOT CAUSES:
1. Sugar and cornstarch conveying equipment was not designed or maintained to minimize the release of sugar and sugar dust into the work area.
2. Inadequate housekeeping practices resulted in significant accumulations of combustible sugar and sugar dust on the floors and elevated surfaces throughout the packing buildings.
3. Imperial Sugar emergency evacuation plans were inadequate. Emergency evacuation drills were not conducted, and prompt worker notification to evacuate in the event of an emergency was inadequate.

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A February 7, 2003, explosion and fire inside a vent collection system (VCS) at Technic Inc., in Cranston, Rhode Island, critically injured one employee, who suffered permanent eye damage and chemical burns to his face and upper body. Eighteen other employees were sent to the hospital for medical evaluations, and the fire department evacuated the surrounding community. Facility operations were interrupted for several weeks.

The explosion and fire were caused by a violent chemical reaction inside the vent collection system, which was likely initiated when the employee tapped on a duct with a small hammer. The building where the incident occurred housed several chemical processes that were connected to the ventilation system.

KEY ISSUES:
• INCOMPATIBLE CHEMICAL MIXING
• PROCESS SAFETY REVIEW
• MANAGEMENT OF CHANGE
• PREVENTIVE MAINTENANCE
• EMERGENCY PLANNING & RESPONSE

ROOT CAUSES:
1. Technic did not conduct a process safety review as a part of the engineering process to identify and evaluate the hazards associated with installing a vent collection system to handle the exhausts from multiple processes.
2. Technic did not identify and evaluate the hazards created by changes to facility processes and equipment (i.e., management of change).

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A February 20, 2003, dust explosion at the CTA Acoustics, Inc. (CTA) facility in Corbin, Kentucky, killed seven and injured 37 workers. This incident caused extensive damage to the production area of the 302,000-square-foot plant. Nearby homes and an elementary school were evacuated, and a 12-mile section of Interstate 75 was closed. The largest CTA customer, Ford Motor Company, temporarily suspended operations at four automobile assembly plants because CTA had produced acoustic insulation products for those plants, as well as for other industrial and automotive clients.

KEY ISSUES:
• COMBUSTIBLE DUST HAZARD AWARENESS
• WORK PRACTICES
• BUILDING DESIGN
• PRODUCT STEWARDSHIP

ROOT CAUSES:
1. CTA management did not implement effective measures to prevent combustible dust explosions.
2. The CTA cleaning and maintenance procedures for production lines did not prevent the accumulation of unsafe levels of combustible dust on elevated flat surfaces.
3. The CTA incident investigation program did not ensure that all oven fires were investigated and that underlying causes were identified and resolved.
4. The Borden Chemical product stewardship program did not explicitly convey to CTA the explosive hazards of phenolic resins.
5. The original building design and subsequent building modifications did not effectively address the fire and explosion hazards associated with combustible dusts.

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On April 25, 2002, a chemical waste-mixing incident occurred at Kaltech Industries Group, Inc., a sign manufacturer located in the Chelsea district of New York City. At least 36 people were injured, including members of the public and six firefighters. Kaltech employees were consolidating hazardous waste from smaller containers into two larger drums when the explosion and fire occurred.

The Kaltech facility was located in a mixed-occupancy building in a densely populated urban area. Because the highly confined workspace in the basement offered limited pathways for the explosion to vent, there was extensive damage to the 10-story building. Street traffic was restricted for several days, and building tenants faced significant business interruptions.

KEY ISSUES:
• HAZARD COMMUNICATION
• HAZARDOUS WASTE HANDLING
• MUNICIPAL OVERSIGHT

ROOT CAUSES:
1. Kaltech did not develop or maintain a chemical hazard communication program in accordance with established OSHA standards.
2. Kaltech did not manage its hazardous waste in accordance with established EPA regulations.

Image Credit: CSB