January, 2011

This is a repeating event

201131JanAll DayHoeganaes Fires 2010Hoeganaes Gallatin (US-TN) Origin: CSB Lessons:Compliance with Standards,Incident Investigation,Process KnowledgeIndustry:Metal ProcessingCountry:United StatesLanguage:ENLoC:Operator error

Summary

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

Origin

CSBUS Chemical Safety Board

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