SACHE Workshop 2005

1. SACHE Workshop 2005 Combustible Dust: Recognizing the Hazard

2. Topics • Introducing the CSB • Dust Explosion Case Histories • Size and Scope of the Problem • Causal Factors • Keys to Prevention • CSB Dust Study

3. 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

4. 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.

5. 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

6. CSB Case Histories • West Pharmaceutical Services (completed) • CTA Acoustics (completed) • Hayes Lemmerz International (pending)

7. West Pharmaceutical Services • Kinston, NC • January 29, 2003 • Polyethylene Powder

8. Video courtesy of Lenoir County, NC Department of Emergency Services

9. West Pharmaceutical Services

10. 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

12. 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

13. CTA Acoustics • Corbin, KY • February 20, 2003 • Phenolic Resin

14. CTA Acoustics

15. 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

17. 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

18. Hayes Lemmerz International • Huntington, IN • October 29, 2003 • Aluminum Dust

19. Hayes Lemmerz International

20. Hayes Lemmerz • 1 dead, 6 injured • Scrap remelting equipment & dust collector damaged • Final investigation report pending

21. Other Notable Dust Explosions • Malden Mills (1995) • Ford River Rouge Power Plant (1999) • Jahn Foundry (1999) • Rouse Polymerics (2002)

22. Malden Mills Industries • Methuen, MA • December 11, 1995 • 37 injured • Nylon fiber explosion

23. Ford River Rouge Power Plant • Dearborn, MI • February 1, 1999 • 6 dead, 30 injured • Secondary coal dust explosion

24. Jahn Foundry • Springfield, MA • February 25, 1999 • 3 dead, 9 injured • Phenolic resin explosion

25. Rouse Polymerics, International • Vicksburg, MS • May 16, 2002 • 5 dead, 7 injured • Rubber dust explosion

26. A few isolated cases, or a big problem? • 197 Incidents since 1980 • 109 Fatalities • 592 Injuries

27. …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.

28. Dust Incidents/Year 1998 2003

29. Thin Dust Layers Can Be Hazardous

30. Materials involved in incidents

31. Incidents occur in many industries

32. 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

33. 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

34. 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

35. Hazard Evaluation • Often, no hazard analysis performed • Focus on exposure hazards but not facility process safety issues

36. 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

37. Housekeeping • The worst damage from a dust explosion is often the result of one or more secondary explosions.

38. Secondary Dust Explosion Mechanism Dust settles on flat surfaces Some event disturbs the settled dust into a cloud Dust cloud is ignited and explodes

39. Thin Dust Layers Can Be Hazardous

40. Change Management • Major modifications performed without adequate design review, hazard analysis or documentation

41. 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

42. 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

43. CSB’s Dust Explosion Study • Dust explosions are serious safety concern • Effects are significant • No federal regulation • Common issues

44. Conclusion • Most important key to prevention is increasing awareness of the hazard

45. For more information… www.csb.gov

46. To contact me: Dust@csb.gov