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Chemical Safety Board Investigation Finds CTA Acoustics
Explosion Caused by Dust Hazard That Was Known to
Management, Phenolic Resin Supplier
For more information, go to:
CTA Acoustics Investigation Information Page
UPDATED: London, KY, February 15, 2005, 9 p.m. EST - By a
vote of 3-0, the U.S. Chemical Safety and Hazard
Investigation Board (CSB) tonight approved the final
report on the phenolic resin dust explosion at CTA
Acoustics. In approving the staff report, the Board added
a root cause related to Borden Chemical's product
stewardship program (Borden Chemical supplied phenolic
resin powder to CTA). The report identified four other
root causes related to CTA's safety systems and the design
of the CTA facility by former owner CertainTeed. The full
report, as amended, will be available soon from CSB.gov,
along with a transcript and videotape of the public
meeting.
London, KY, February 15,
2005 – The U.S. Chemical Safety and Hazard Investigation
Board (CSB) today released its final report on the
investigation of the 2003 accident at CTA Acoustics Inc.
in Corbin, KY, determining that the fatal dust explosion
and fire could have been prevented because the hazards of
the material involved were known to several parties,
including CTA management and raw material supplier Borden
Chemical. The February 20, 2003, accident killed seven
workers and injured 37 others.
The report is set to be
considered today by the full Board at a public meeting at
the London Community Center, 529 South Main Street, at 7
p.m. Investigators will present their findings and
recommendations followed by public comment and a vote on
whether to accept the report.
The CSB found the accident
occurred when a cloud of phenolic resin dust, generated
during the cleaning of a production line, was ignited by a
fire in a malfunctioning oven. Phenolic resin powder was
one of the raw materials CTA used to produce acoustic
fiberglass insulation for automobiles.
At the time of the
accident, workers were cleaning a production line known as
Line 405. The CSB found that dust removal activities --
involving the use of compressed air, electric fans, and
brooms -- formed a dust cloud near the Line 405 oven. The
oven had a malfunctioning temperature controller, which
caused it to run hot. The door was left open to help
control the temperature. Investigators concluded that a
fire developed inside the 405 oven and ignited the dust
cloud. The first dust explosion and fire set off
subsequent explosions through several production lines.
The explosions destroyed much of the production area.
The CSB found that ovens at
the plant had a history of small fires caused by the
accumulation of combustible material. These fires were
routinely put out by plant personnel using extinguishers
and hoses, but on the morning of the incident workers were
occupied by the cleaning activity and none were in the
vicinity of the oven.
Investigators found that
CTA had been aware that combustible dust in the plant
could explode, but did not communicate this hazard to
workers or modify operating procedures or the design of
the plant. CTA company memoranda and safety committee
meeting minutes from 1992 through 1995 showed a concern
about creating explosive dust hazards when cleaning the
production line. Further concerns were raised in 1997
documents.
Investigators said that
Borden Chemical’s material safety data sheets (MSDSs) for
the resin it supplied to CTA did note that resin dust was
combustible, but did not explicitly warn of the dust’s
explosive properties. In addition, Borden did not tell its
customers of the explosion hazard following a catastrophic
explosion and fire involving a similar Borden phenolic
resin used at the Jahn Foundry in Springfield, MA, in
1999, an accident that killed three people.
The CSB also found that CTA
plant ovens had a history of small fires due to the
accumulation of combustible material inside.
Other key findings of the
report include:
- The Kentucky Office of
Occupational Safety and Health conducted several
comprehensive inspections of CTA, but did not cite the
combustible dust hazard.
- Numerous inspections by
insurance companies failed to identify phenolic resin dust
as an explosion hazard in an eight-year period prior to
the accident.
- The Kentucky fire
marshal’s office, which has the responsibility to enforce
fire safety standards, does not routinely inspect
industrial facilities, and had never inspected the CTA
facility, which was built in 1972.
CSB Chairman Carolyn
Merritt said, “What this report reveals are many missed
opportunities to prevent this explosion. The company, the
supplier, state regulators, and private insurers all
overlooked the deadly hazard posed by combustible dust
that was allowed to accumulate and which was handled
unsafely during manufacturing and maintenance operations.”
“Following the Jahn Foundry
explosion in 1999, Borden drafted a letter to its phenolic
resin customers to alert them to the danger but never sent
it,” Ms. Merritt said, adding that many of the CSB’s
recommendations are aimed at making certain that adequate
warnings of combustible dust hazards be communicated
effectively in the future.
The report also points out
that neither the federal Occupational Safety and Health
Administration (OSHA) nor the Kentucky Office of
Occupational Safety and Health has a comprehensive
standard that addresses combustible dust safety for
industrial facilities.
“In order to gain a greater
understanding of the hazards of combustible dust in
industrial settings, we are now conducting a nationwide
study of such accidents,” said Bill Hoyle, lead
investigator. “Preliminary information indicates more than
150 serious industrial dust explosions have occurred in
the U.S. over the last 20 years. We will be looking at the
adequacy of federal and state regulations covering these
industrial hazards, as well as building and fire codes,”
Mr. Hoyle added.
The accident occurred only
a few weeks after a polyethylene dust explosion and fire
killed six workers at a rubber manufacturing plant in
Kinston, NC, which the CSB investigated (the report is
available at www.csb.gov). The agency also is
investigating a dust explosion at the Hayes Lemmerz plant
in Huntington, IN, which occurred October. 29, 2003.
In its report, the CSB
recommended CTA develop a program using the good practice
guidelines of the National Fire Protection Association (NFPA)
including:
- Minimizing surfaces where
combustible dust could accumulate.
- Ensuring its facility is
designed to prevent the spread of fires or explosions
involving combustible dust by using firewalls and blast
resistant construction.
- Cleaning process areas
frequently, using appropriate dust cleaning methods, to
prevent accumulation of dust.
- Ensuring that workers
know the dangers of combustible dust and are appropriately
trained.
CSB investigators listed
several root and contributing causes:
- CTA management did not
implement effective measures to prevent combustible dust
explosions, such as those contained in NFPA Standard 654,
and did not communicate the hazards to its workers. - The
CTA cleaning and maintenance procedures for production
lines did not prevent the accumulation of unsafe levels of
combustible dust.
- The facility design by
the original owner, CertainTeed Corporation, and
subsequent building modifications by CTA, did not
adequately address the fire and explosion hazards
associated with combustible dusts. - The Borden Chemical
product stewardship program did not adequately convey to
CTA the explosive hazards of phenolic resin.
- The design and
installation of the Line 405 oven did not include adequate
fire protection equipment.
- The CTA incident
investigation program was inadequate.
- CTA did not have
effective procedures for evaluating the hazards associated
with non-routine operating conditions on line 405.
Other CSB recommendations
included one urging that Borden Chemical strengthen
warnings in its phenolic resin MSDSs and distribute
additional educational material about the dust explosion
hazard. The report also recommends that the Kentucky OSH
office distribute an educational bulletin on preventing
combustible dust explosions. The Kentucky Office of
Housing, Buildings, and Construction, which oversees the
office of the state fire marshal, was urged to identify
sites that handle combustible dusts in order for them to
be inspected.
The CSB is an independent
federal agency charged with investigating industrial
chemical accidents. The agency’s board members are
appointed by the president and confirmed by the Senate.
CSB investigations look into all aspects of chemical
accidents, including physical causes such as equipment
failure as well as inadequacies in safety management
systems.
The Board does not issue
citations or fines but does make safety recommendations to
plants, industry organizations, labor groups, and
regulatory agencies such as OSHA and EPA. Further
information about the CSB is available from www.csb.gov.
For more information,
contact Daniel Horowitz, 202-441-6074 (cell), Sandy
Gilmour, 202-251-5496 (cell) or Kara Wenzel, 202-577-8448
(cell).
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Acetylene Service Company Gas Explosion |
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Perth Amboy, NJ, January 25, 2005 |
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Building
shows damage following fatal gas explosion in an
exterior wooden shed Jan. 25. |
Incident
Description
On January
25, 2005, a gas explosion killed three workers at the
Acetylene Service Company plant in Perth Amboy, NJ.
The blast originated in a wooden shed located near six
large storage tanks that received liquid waste from
the plant's acetylene generating system. The plant
produces, repackages, and distributes acetylene used
in welding.
Investigation Status
A CSB
investigation is underway.
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Marcus Oil and Chemical Tank Explosion |
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Houston, TX, December 3, 2004 |
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Fire
rages at the Marcus Oil facility on evening of
Dec. 3 following powerful tank explosion. |
Incident Description
On the
evening of December 3, a storage tank failed
catastrophically at the Marcus Oil and Chemical
polyethylene wax facility in Houston. The blast,
which was felt up to 20 miles from the plant site,
ignited large fires that burned for several hours,
and two firefighters were injured during the
emergency response. Off-site buildings near the
facility – including two churches, a house, and a
social club – exhibited structural damage, such as
broken windows and cracked walls.
Investigation Status
A CSB
investigation is underway.
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