August, 2004

This is a repeating event

200419AugAll DaySterigenics Explosion 2004Sterigenics International, Inc Ontario (US-CA) Origin: CSB Lessons:Asset integrity,Competency,Incident Investigation,Risk AssessmentIndustry:Life SciencesCountry:United StatesLanguage:ENLoC:Confined explosion

Summary

On August 19, 2004, an explosion at the Sterigenics International, Inc., ethylene oxide (EO) sterilization facility in Ontario, California, injured four workers and caused extensive damage to the 66,000 square-foot facility. Flying glass from the control room windows was responsible for all of the injuries, and both the facility structure and equipment sustained severe damage. The Sterigenics plant and neighboring facilities were evacuated, and plant operations were disrupted for 9 months.

Sterigenics is a contract medical sterilization services provider that specializes in various types of sterilization in the U.S. and around the world. Its EO facility in Ontario performs services for manufacturers of a variety of medical products such as disposable syringes, urinary tract catheters, and cardiovascular stints and valves.

KEY ISSUES:
• PROCESS HAZARD ANALYSIS
• PROCESS DESIGN
• EMPLOYEE TRAINING
• LESSONS LEARNED

ROOT CAUSES:
1. Engineering controls installed at the facility did not prevent an explosive concentration of ethylene oxide (EO) from reaching the oxidizer.
2. The maintenance supervisor did not fully understand the hazards associated with the process.


Image Credit: CSB

Origin

CSBUS Chemical Safety Board

X