CSB Case Study Cites Deficient Management Systems, Inadequate Safeguards in Explosion and Fire

October 30, 2003

Investigators from the U.S. Chemical Safety Board (CSB) have concluded that an explosion and fire at Catalyst Systems Inc. in Gnadenhutten, Ohio, last January most likely occurred when 200 pounds of benzoyl peroxide in a vacuum dryer rapidly decomposed. The runaway chemical reaction produced large volumes of gas under high pressure.

Presenting their findings in the form of a case study to the five-member CSB Board in Washington, DC, investigators said they were unable to determine the specific initiating event that led to the thermal decomposition, in which a chemical breakdown produces heat that leads to further breakdown. But the study noted the likely underlying cause of the accident was that management had not put in place a proper hazard identification system.

The force of the explosion propelled the heavy vacuum dryer like a rocket across the room and through a wall, causing extensive damage to the building, but missing workers eating lunch just 35 feet away in the same room.

The operators described thick black smoke with rolling flames and a loud boom. They quickly exited the building. One worker received a puncture wound in his shoulder, most likely from flying debris.

CSB Board Chairman Carolyn Merritt said: "The workers were fortunate they were not standing by the vacuum dryer at the time of the explosion. This is another example of the dangers of not recognizing the inherent hazards of materials being handled, not using properly designed equipment, and not performing hazard identification studies. We noted this in our major report on reactive hazards last year, and I remain determined to continue our work focusing the industry on these hazards. Small businesses also need to know they must follow safe handling practices."

The purpose of the process was to concentrate benzoyl peroxide, or BPO, to 98 percent by drying it. In this form BPO is the consistency of beach sand, and can decompose explosively when overheated. BPO is used to make a number of products, including plastics, silicone rubber, and automobile body putty.

The process, involving highly reactive materials, was not sufficiently evaluated by management, the study said, adding that Catalyst Systems had no program to formally take the hazards, generally well known in the industry, into account in the design of the dryer. The study found the dryer had been purchased second-hand, with no wiring diagram or engineering drawings. No written operating procedures were developed for drying the chemical – only verbal instructions were provided operators.

Lead investigator Lisa Long said: "The accident might have been avoided had the company evaluated the potential hazards in their process and used this information to design appropriate safeguards into the drying process."

The case study notes that management systems – including explicit, detailed procedures and practices and clear statements of accountability for implementing the procedures and practices -- are vital for preventing catastrophic accidents, particularly where hazardous materials are used. Management systems are developed after considering a range of information, including the hazardous properties of chemicals and equipment design. The case study says, "Catalyst Systems did not have a process safety management program in place, nor were employees trained in the use of these systems."

While not determining the specific initiating event of the explosion, the study listed several probable sources. These included failure of a temperature probe, a hot spot in the dryer, failure of the vacuum pump, and leaving the chemical in the dryer too long.

The CSB is an independent federal agency charged with investigating industrial chemical accidents. CSB investigations look into all aspects of such events, including physical causes such as equipment failure as well as inadequacies in safety management systems. Typically, the investigations involve extensive witness interviews, examination of physical evidence, and chemical and forensic testing. 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.

NIOSH, ASSE to Collaborate on Research to Prevent Work-Related Deaths, Injuries

The Centers for Disease Control and Prevention's (CDC) National Institute for Occupational Safety and Health (NIOSH), part of the Department of Health and Human Services, has signed an agreement with the American Society of Safety Engineers (ASSE) to collaborate on research to prevent work-related deaths and injuries.

NIOSH Director Dr. John Howard and ASSE President James "Skipper" Kendrick, CSP, signed the agreement at the National Occupational Injury Research Symposium (NOIRS) 2003 in Pittsburgh.

"New technology and other changes in the 21st century workplace have created exciting opportunities for advancing workplace safety," said NIOSH Director Dr. John Howard. "We are pleased to join with ASSE in laying the groundwork to explore, design, evaluate, and introduce innovative tools and approaches for making workplaces safer."

"We value the resources NIOSH brings to this collaboration," said ASSE's Kendrick. "The more tools our members have, the likelier we are to see our co-workers arrive at work and return home safe and without injuries. That is very important to all of us."

Every day, 16 people on average die from work-related injuries and, every year, about 3.6 million non-fatal occupational injuries are treated in hospital emergency rooms, according to NIOSH estimates. Under the new agreement, which will continue until December 31, 2004, NIOSH and ASSE will partner on projects to reduce work-related injuries by:

  • Developing and disseminating information on worker safety and health;
  • Participating in conferences where occupational safety and health issues are proactively addressed;
  • Advancing the effectiveness of occupational safety and health research; and
  • Promoting and facilitating implementation of research results

NIOSH is the CDC agency that conducts research and makes recommendations for preventing work-related injuries, illnesses, and deaths. Committed to protecting people, property, and the environment, ASSE is the largest and oldest professional safety organization, representing more than 30,000 occupational safety, health, and environmental professional members who manage, supervise, and consult on safety, health, transportation, and environmental issues.

Failing to Correct Previously-Cited Safety Hazards Leads to $120,000 in Proposed OSHA Penalties

As the result of its alleged failure to correct workplace safety hazards for which it was previously cited by OSHA, Chester Manufacturing Co. of Tonawanda, N.Y., has now been cited by OSHA for three "failure to abate" violations, which carry $120,000 in proposed penalties.

OSHA conducted an initial inspection of the company, which manufactures small metal parts for the automotive industry, beginning on July 22, 2002 in response to a complaint. In December 2002, the employer was issued citations alleging five serious violations of the regulation relating to the safe operation of mechanical power presses. The current action resulted from a follow up inspection conducted April 21, 2003 after the employer repeatedly failed to respond regarding any corrective action taken to ensure employees would not be injured by mechanical power presses.

"OSHA does not often have cause to issue 'failure to abate' citations," said Labor Secretary Elaine L. Chao, "but this employer's blatant disregard for the safety and health of its employees was particularly egregious and resulted in the proposed maximum penalty allowed under the law of $120,000."

Chester Manufacturing Co. has now been cited for the following alleged failure to abate violations:

  • Failing to install guards on 2-hand trip mechanisms on mechanical power presses to protect employees from unintended operations. ($30,000 proposed penalty)
  • Failing to incorporate anti-repeat feature on a full revolution mechanical power press in order to prevent double-cycling, which can cause finger amputation. ($30,000 proposed penalty)
  • Failing to establish and implement a regular press inspection schedule to ensure that mechanical power presses are in good working order with all required safeguards prior to use. ($60,000 proposed penalty)

OSHA issues a serious violation when there is a substantial probability that death or serious physical harm could result, and the employer knew, or should have known, of the hazard. A failure to abate violation exists when an item of equipment or condition previously cited has never been brought into compliance and is noted at a later inspection.

California Workplace Fatalities Continue to Decline

The number of workplace fatalities in California declined by 8% in 2002 according to the Department of Industrial Relation's (DIR) Division of Labor Statistics and Research. The number of workers who died on the job in 2002 was 478, down 25% since 1992 when the U.S. Bureau of Labor Statistics began compiling work-related fatalities.

"While one life lost is too many, I am pleased that our focus on workplace safety is paying off," said Chuck Cake, (DIR) acting director. "The Davis administration has worked hard to protect workers by increasing inspections and enforcement of existing laws which creates a strong incentive for compliance," added Cake.

The number of workplace fatalities has declined steadily over the past five years at a rate of 7-8% per year. In prior years the number of fatalities hovered around 650 and showed no significant reductions.

Among the preliminary findings for 2002 fatalities were:

  • More workers -- 43% -- died from transportation accidents then any other type of workplace mishap.
  • The occupation that suffered the highest number of fatalities was truck drivers.
  • Both the transportation and services industries had the highest number of fatalities with 81 deaths each, followed by construction with 78 fatalities.
  • Falling at work showed the sharpest decline with 34% fewer fatalities.

Workplace fatalities in 2002 by industry sector were: transportation, 16.9%; services-such as business services, auto repair services and garages 16.9%; construction 16.3%; agriculture/forestry/fishing 12.6%; manufacturing 10.5%; retail trade 9%; wholesale trade 1.9%; finance/insurance/real estate 1.7%; and mining 1%.

Leading the category of work-related fatalities by occupation in 2002 were operators, fabricators, and laborers at 31.2%; followed by precision production, craft, and repair at 18.4%; farming, forestry, fishing at 12.3%; technical, sales and administration at 11.9%; service occupations at 11.3%; managing and professional specialties at 9.2%; and military occupations at 5.6%.

The national census of fatal workplace injuries and illnesses identifies, verifies and profiles workplaces of all employees in the private sector, as well as individuals who are self-employed, civilian and military government workers. Census sources include Cal/OSHA and federal OSHA reports, law enforcement data, workers' compensation claims, coroners' reports and news reports.


CSB Calls on New York City Lawmakers to Adopt Recommendations on Modernizing Fire Code

Appearing before the New York City Council Fire and Criminal Justice Services Committee, U.S. Chemical Safety Board (CSB) member Dr. Gerald Poje told local lawmakers that modernizing the city’s 85-year-old fire code is essential for preventing chemical accidents like last year’s building explosion in downtown Manhattan.

“There are many overlapping safety requirements under local, state, and federal regulations,” Dr. Poje said. “However, for small businesses, a city fire inspector is often the only government safety official who will regularly visit and enforce those requirements. In those cases, city fire codes and inspections are the only line of defense a community has to protect itself from hazardous materials accidents. There are excellent model code provisions in existence, and the Board urges New York City to adopt them, as so many other jurisdictions have already done.”

CSB’s investigation of the April 25, 2002, building explosion concluded that Kaltech Industries, a small commercial sign manufacturer that occupied the basement, had improperly mixed two incompatible waste chemicals, lacquer thinner and nitric acid, without following basic safety requirements.

City fire inspectors visited the facility prior to the accident, but the city fire code they were authorized to enforce lacks modern hazardous materials controls. On September 30, 2003, the CSB voted to recommend that New York City revise that code to require chemical labeling, separation of incompatible materials, submission of a chemical inventory and management plan, and provision of training and safety information to employees.

Propane Distributor's Failure to Follow Safety Procedures Brings OSHA Penalties Totaling $75,600

A Tulsa, Okla., company's alleged failure to provide a safe working environment by exposing workers to a fire and explosion has resulted in three citations from OSHA. Proposed penalties total $75,600.

OSHA began an investigation of Airgas Mid-South Inc., on Aug. 18, in response to a fire and explosion that occurred when a liquefied propylene cylinder vented gas ignited, leading to the explosion. Extensive damage occurred to the facility, as well as nearby local residential properties.

"The company knew exposing gas-contained cylinders to high heat could result in conditions with a potential for fire and explosion," said James Brown, OSHA area director in Oklahoma City. "It is fortunate that no worker was injured in this case."

Airgas Mid-South Inc., headquartered in Tulsa, distributes gas cylinders to medical and industrial businesses. The company employs about 784 employees nationwide with 125 of them working in Tulsa.

OSHA cited the employer with one alleged willful violation for exposing gas-compressed cylinders to solar heating causing them to expel gas, which resulted in the fire and explosion. A willful violation is one in which there is evidence of an intentional violation of the OSHA Act or plain indifference to its requirements.

The two alleged serious violations were issued for failing to perform an initial process hazard analysis for gases such as anhydrous ammonia and propylene, and for not providing appropriate powered industrial trucks for use in a hazardous environment.

Airgas Mid-South has 15 working days from receipt of the citations to comply, request an informal conference with the Oklahoma City area office, or to contest the citations and penalties before the independent Occupational Safety and Health Review Commission.