september 19, 2005 sache workshop 2005 combustible dust: recognizing the hazard
TRANSCRIPT
September 19, 2005
SACHE Workshop 2005
Combustible Dust:Recognizing the Hazard
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Topics
• Introducing the CSB• Dust Explosion Case Histories• Size and Scope of the Problem• Causal Factors• Keys to Prevention• CSB Dust Study
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Introducing the CSB• Authorized by 1990 Clean Air Act
Amendments• Governed by a Board appointed by
the President for 5 year terms• Independent federal agency• Authorized to investigate accidents
and recommend accident prevention • Does not promulgate regulations or
issue fines or penalties
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CSHIB Mission
• To promote prevention of industrial chemical accidents that harm employees, damage the environment and endanger the public through scientific investigations that determine root and contributing cause, and implementation of recommendations to reduce the risk and consequences of accidental chemical releases.
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CSB Common Findings• Failure to recognize potential hazards• Failure to address near miss warning events• Failure to maintain safety systems• Lack of technical expertise• Lack of proper engineering and design• Lack of maintenance of production systems• Lack of procedures or training for abnormal
operations • Failure to plan for emergency response• Failure to prepare community for emergency
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CSB Case Histories
• West Pharmaceutical Services (completed)
• CTA Acoustics (completed)
• Hayes Lemmerz International (pending)
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West Pharmaceutical Services
• Kinston, NC– January 29, 2003– Polyethylene Powder
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Video courtesy of Lenoir County, NC Department of Emergency Services
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West Pharmaceutical Services
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West Pharmaceutical Services
• 6 dead, 38 injured• Facility virtually destroyed• Rubber compounding process• Fuel for dust explosion was
polyethylene powder– Used as a slab dip for sheets of rubber– Dried residue accumulated above
suspended ceiling
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West Pharmaceutical- Selected Findings• MSDS dip did not convey dust hazard• Workers unaware of hazard• Material review did not address dust
explosion hazard• Inspectors failed to identify hazard• Area above ceiling not cleaned• Pertinent fire codes not applied
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CTA Acoustics• Corbin, KY
– February 20, 2003– Phenolic Resin
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CTA Acoustics
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CTA Acoustics
• 7 dead, 37 injured• Widespread facility damage• Fuel was phenolic resin
– Lofted by cleaning– Ignited by flames from open door of
curing oven– Secondary explosions traversed facility
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CTA Acoustics - Selected Findings• Measures not implemented to
prevent dust explosions• Hazard not communicated to
workforce• Inefficient baghouse operation• Lack of housekeeping• Prior inspectors failed to identify
hazard• Pertinent fire codes not applied
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Hayes Lemmerz International
• Huntington, IN– October 29, 2003– Aluminum Dust
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Hayes Lemmerz International
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Hayes Lemmerz
• 1 dead, 6 injured• Scrap remelting equipment & dust
collector damaged• Final investigation report pending
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Other Notable Dust Explosions
• Malden Mills (1995)• Ford River Rouge Power Plant (1999) • Jahn Foundry (1999)• Rouse Polymerics (2002)
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Malden Mills Industries
– Methuen, MA– December 11, 1995– 37 injured– Nylon fiber explosion
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Ford River Rouge Power Plant
– Dearborn, MI– February 1, 1999– 6 dead, 30 injured– Secondary coal dust explosion
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Jahn Foundry
– Springfield, MA– February 25, 1999– 3 dead, 9 injured– Phenolic resin explosion
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Rouse Polymerics, International
– Vicksburg, MS– May 16, 2002– 5 dead, 7 injured– Rubber dust explosion
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A few isolated cases, or a big problem?
• 197 Incidents since 1980• 109 Fatalities• 592 Injuries
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…and this did NOT include
– Grain handling facilities– Coal mining incidents– Incidents in non-manufacturing
sectors (universities, hospitals, military, retail)
– Transportation related incidents – Incidents occurring outside the U.S.
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Dust Incidents/Year
0
2
4
6
8
10
12
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16
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1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Year
Nu
mb
er
1998
2003
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Thin Dust Layers Can Be Hazardous
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Materials involved in incidents
Metal24%
Wood22%
Food19%
Plastic15%
Other5%Inorganic
5%
Coal 10%
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Incidents occur in many industries
Food products18%
Lumber & wood products
13%
Chemical manufacturing
12%Primary metal industries
11%
Other10%
Electric services9%
Fabricated metal products
9%
Rubber & plastic products
7%
Equipment manufacturing
6%
Furniture & fixtures5%
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Incidents occur nationwide• Illinois 21• California 19• Ohio 13• Indiana 12• Pennsylvania 11• Iowa 10• North Carolina 8• Maryland 8• Virginia 7• Oregon 6• New Hampshire 6• Minnesota 6• Kentucky 3
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Causal Factors for Dust Explosions
• Lack of hazard awareness• Inadequate hazard evaluation• Failure to comply with NFPA
standards• Poor housekeeping• Inadequate change management• Failure to investigate and respond to
previous incidents
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Awareness of the Hazard
• MSDSs do not convey the explosion hazard
• Employees not trained about dust explosion prevention
• Third-party inspections with no recognition of the hazard
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Hazard Evaluation
• Often, no hazard analysis performed• Focus on exposure hazards but not
facility process safety issues
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NFPA Standards
• NFPA-654, NFPA-484 and others have been around in one form or another for decades
• Adopted as fire code in many states• Little or no inspection or enforcement
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Housekeeping
• The worst damage from a dust explosion is often the result of one or more secondary explosions.
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Dust settles on flat surfaces
Some event disturbs the settled dust into a cloud
Dust cloud is ignited and explodes
Secondary Dust Explosion Mechanism
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Thin Dust Layers Can Be Hazardous
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Change Management
• Major modifications performed without adequate design review, hazard analysis or documentation
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Incident Investigation
• Precursor events – Small deflagrations or fires– Events at other facilities– “Whew” events (if not for the safety
device, this could have been bad)• Not reported• Not investigated• No corrective actions taken• Findings not communicated to
employees
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Keys to Prevention
• Increased hazard awareness– Improved MSDSs– Dust explosions taught in undergrad
curriculae– Access to NFPA standards
• Applied principles of PSM– Change management– Hazard evaluation– Incident investigation– Hazard communication
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CSB’s Dust Explosion Study
• Dust explosions are serious safety concern
• Effects are significant• No federal regulation• Common issues
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Conclusion
• Most important key to prevention is increasing awareness of the hazard
September 19, 2005
For more information…
www.csb.gov
