On Sunday, August 28, 2016, at approximately 12:10 pm, a nitrous oxide trailer truck exploded at the Airgas manufacturing facility in Cantonment, Florida. The explosion killed the only Airgas employee present and heavily damaged the facility, halting nitrous oxide manufacturing at Cantonment indefinitely.

KEY ISSUES:
• PROCESS SAFETY MANAGEMENT SYSTEM
• INHERENTLY SAFER DESIGN
• REACTIVE HAZARDS
• HAZARD ANALYSIS
• INEFFECTIVE SAFEGUARDS

ROOT CAUSES:
1. Airgas did not evaluate inherently safer design options that could have eliminated the need for the pump;
2. Airgas never evaluated its process to identify and control process safety hazards;
3. Airgas did not effectively apply the hierarchy of controls to the safeguards that the company used to prevent a possible nitrous oxide explosion;
4. Airgas installed equipment that increased the likelihood of an explosion without performing a management of change safety review;
5. Airgas did not apply an essential industry safety instrumentation standard, or key elements of a voluntary safe storage and handling standard, both of which are intended to prevent nitrous oxide explosions;
6. Airgas safeguards that failed to prevent the explosion include an automatic shutdown safety control and an explosion prevention device;
7. Airgas failed to apply lessons from previous nitrous oxide explosions; and
8. Airgas did not provide its Cantonment facility with an appropriate level of technical staffing support.

Image credit: CSB