september 19, 2005 sache workshop 2005 combustible dust: recognizing the hazard

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

14

16

18

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

September 19, 2005

To contact me:

Dust@csb.gov