An explosion and flash fires occurred at the US Ink manufacturing facility in East Rutherford, New Jersey, on Tuesday, October 9, 2012. Seven workers suffered burn injuries when they congregated at the entrance to the ink mixing room after hearing a loud thump from the newly installed dust collection system on the top of the facility and seeing signs of an initial flash fire from a bag dumping station. A second flash fire then occurred that led to the employee injuries.

KEY ISSUES:
• COMBUSTIBLE DUST
• ENGINEERING DESIGN
• MANAGEMENT OF CHANGE
• PROCESS HAZARD ANALYSIS
• HAZARD COMMUNICATION
• MANAGEMENT OVERSIGHT
• REGULATORY OVERSIGHT

ROOT CAUSES:
1. Inadequate automatic fire alarm systems
2. New installations & modifications did not consider PHA, MOC, documentation, contractors & training
3. Organisational change management & knowledge transfer deficiencies

Image credit: CSB