CSB Declares Full Root-Cause Investigation of Fatal Accident at PVC Plant in Illinois

April 22, 2004

Calling the accident at the Formosa Plastics plant in Illiopolis, Illinois "among the most serious that the Board has investigated in more than six years," U.S. Chemical Safety and Hazard Investigation Board (CSB) Chairman Carolyn W. Merritt announced the Board would conduct a full investigation to determine the root causes of the tragedy and develop safety recommendations to prevent similar accidents in the future. Depending on its course, that investigation may take up to a year or more to complete.

The explosions and fire at the polyvinyl chloride (PVC) plant just before 11 p.m. on Friday, April 23, 2004, killed four workers, injured a number of others including two who were reported in critical condition, destroyed part of the facility, and caused a large public evacuation.

"First and foremost, our thoughts are with the injured and the families of the victims. Based on the human toll, the damage to the plant, the hazards of the materials used, and the impact on the public, the U.S. Chemical Safety Board has begun a full, independent, federal investigation of the root causes of the disaster at Formosa Plastics. This investigation will continue until we understand what happened, why it happened, and how best to prevent it from ever happening again."

CSB investigators have conducted interviews with plant management including the operations supervisor and safety director. They have also begun interviewing plant workers. Members of the CSB team have only been able to view the plant destruction at a distance of a quarter-mile due to the safety concerns.

Chairman Merritt said CSB investigators may initially be at the site for a week or more, interviewing workers, eyewitnesses, and emergency responders; examining and collecting forensic evidence; and reviewing the company’s records, procedures, and safety history. There are currently three investigators from CSB headquarters in Washington, DC, at the site and three more will arrive shortly.

Chairman Merritt said, "As we develop preliminary findings in this case, we will provide that information to the affected community. At the end of our investigation, the full Board will come to the area to present its final report."

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. Typically, the investigations involve extensive witness interviews, examination of physical evidence, and chemical and forensic testing.

NIOSH Recommends Ways to Prevent Fatalities From Work-Related Roadway Crashes

At work, more people die in motor vehicle crashes than from any other cause. The U.S. Centers for Disease Control and Prevention’s (CDC) National Institute for Occupational Safety and Health (NIOSH) described leading risk factors for fatal, work-related roadway crashes, and made recommendations for preventing such work-related deaths.

NIOSH presented the findings and recommendations in two companion fact sheets, "Work-Related Roadway Crashes: Who’s at Risk?" and "Work-Related Roadway Crashes: Prevention Strategies for Employers." NIOSH issued the fact sheets in conjunction with World Health Day 2004, the theme of which is road safety.

"The fact sheets provide new information that employers and others can use for assessing risks for motor vehicle injuries and deaths in their work settings, and for taking effective steps to reduce those risks," said NIOSH Director John Howard, M.D.

As a key step in preventing job-related fatalities in motor vehicle crashes, employers should establish and enforce workplace driver safety policies, NIOSH recommended. Occupational safety and health professionals also can help by promoting safe driving practices among employees, supporting collection and analysis of data needed to identify risk factors and interventions, fostering partnerships, and assessing interventions, NIOSH added. Effective strategies for reducing motor-vehicle related crash injuries in the general public can also reduce work-related crash injuries.

NIOSH used two complementary sets of data for determining risk factors in work-related roadway crashes, and for identifying worker populations at highest risk. FARS is a census of all traffic crashes reported to the police in which a person who was injured in the crash died within the next 30 days.

Between 1992 and 2001, job-related motor vehicle crashes accounted for 13,337 deaths among the civilian work force, CFOI data show. Males accounted for 11,931 deaths, or 89 percent of the total, with a fatality rate 6 times higher than that for females. Fatality rates increased sharply beginning with age 55, with the highest rate (6.4 deaths per 100,000 employees) among employees 75 and older.

Worker fatalities due to crashes most often involved collisions between vehicles (49 percent), followed by single-vehicle incidents such as vehicle rollovers that did not involve a collision with another vehicle or with a pedestrian (26 percent), and collisions between a vehicle and a stationary object on the roadside (18 percent). Vehicles occupied by fatally injured employees most often were semi-trucks (28 percent of all fatalities), followed by cars (24 percent), other and unspecified trucks (18 percent) and pickup trucks (12 percent).The highest number and rate of fatal work-related crashes occurred in the transportation, communications, and public utilities industry, which includes commercial trucking (4,358 fatalities, 4.64 per 100,000 full-time employees).

In 1997-2002, 5,798 worker fatalities occurred in 5,626 vehicles, data from FARS show. These data indicate that 56 percent of fatally injured workers were not wearing a seat belt or had no seat belt available, and 28 percent were wearing a seat belt. Factors associated with the worker’s vehicle that were judged to have contributed to the fatal crash were: running off the road or failing to stay in the proper lane (2,599 [46%]), driving over the speed limit or too fast for conditions (1,284 [23%]), driver inattention (609 [11%]), and driver drowsiness (373 [7%]).

As part of a driver safety program, NIOSH recommended, employers should:

  • Provide a key member of the management team with responsibility and authority to set and enforce a comprehensive driver safety policy.
  • Require use of seat belts by all persons in a vehicle used on the job.
  • Select vehicles that provide high levels of occupant protection.
  • Maintain complete and accurate records of driving performance.
  • Stipulate that driving is a task that requires full attention, including instructions to avoid placing or taking cell phone calls while the vehicle is in operation.
  • Set schedules that allow adequate time for employees to make deliveries or visit clients without violating traffic laws or safety regulations.
  • Ensure that employees are properly licensed and trained to operate the vehicle they are assigned.
  • Implement a vehicle maintenance program that includes pre-trip inspections, immediate withdrawal from service of any vehicle with mechanical defects, and regularly scheduled withdrawal of vehicles for comprehensive inspection and maintenance.



Workers' Memorial Day is April 28, 2004

On April 28, 2004, Workers' Memorial Day, the United States will join the international labor community in remembering those workers who have died or been injured on the job. On an average day in the United States, as a result of work-related injuries or illnesses, nearly 11,000 workers are treated in emergency departments, and approximately 200 of these workers are hospitalized (1). An estimated 7,000 private-sector workers require time away from their jobs (2), 15 workers die from their injuries (3), and 134 die from work-related diseases (4). The emotional, economic, and social costs of these injuries and illnesses are immense. In 2001, workers' compensation costs for employers alone totaled $64 billion (5).

Workers' Memorial Day also will commemorate the 33rd anniversary of the signing of the U.S. Occupational Safety and Health Act, which created the National Institute for Occupational Safety and Health within CDC and the Occupational Safety and Health Administration within the U.S. Department of Labor to lead the effort to create safer workplaces. 

Tinnitus Awareness Week: What Is It?

Tinnitus Awareness Week, May 15-22, 2004, is the American Tinnitus Association's nationwide effort to add "tinnitus" to our national vocabulary. Many people understand the concept of "ringing in the ears," but they often don't "get" what it means to have incessant tinnitus, how to prevent tinnitus, or to how get help if they have tinnitus. The ATA's goal is to teach the public that help and treatments are available, that prevention is necessary, and that awareness is key.

CSB Chairman Calls for Improvements in Material Safety Data Sheets

Carolyn Merritt, Chairman of the U.S. Chemical Safety and Hazard Investigation Board (CSB) told a Congressional committee that the safety information accompanying chemical products delivered to industrial plants frequently is deficient, leading to avoidable deaths and injuries. She made her remarks in written testimony delivered to the Senate Health, Education, Labor and Pensions Committee Senate Subcommittee on Employment, Safety and Training, which is holding hearings on the safety information, called Material Safety Data Sheets, or MSDSs.

Ms. Merritt said, “Deficiencies in hazard communication and Material Safety Data Sheets are among the common causes of major chemical accidents that result in loss of life, serious injures, and damage to property and the environment.”

Chairman Merritt cited data and root cause findings from the 19 investigations CSB has conducted since becoming operational in 1998. Deficiencies in communicating hazards on the data sheets were cited in ten of the 19 reports. The deficiencies were found to be an actual root cause, contributing cause, or major causal factor in nine of the ten.

“These nine accidents were responsible for the deaths of 12 workers and injuries to 79 other workers, emergency responders, and members of the public. These totals will likely increase as additional investigations are completed,” she said.

The Material Safety Data Sheets are required in the Hazard Communication Standard promulgated by the Occupational Safety and Health Administration (OSHA). The American National Standards Institute (ANSI) creates voluntary standards on preparing precautionary labels and developing the language for MSDSs.

The Chairman in particular cited the inadequacy of information in data sheets concerning combustible dust dangers that occur in certain chemical processes. Noting the CSB has investigated three major dust explosion accidents over the past year, Ms. Merritt said “The CSB is concerned that neither the OSHA Hazard Communication Standard nor the ANSI standard contains a definition for combustible dust…Employers need this information to accurately assess the hazards of dust in the workplace.”

The Chairman concluded her testimony saying, “The CSB believes that improving the quality of hazard communication and Material Safety Data Sheets will help prevent major chemical accidents and should be an important goal of government agencies as well as the producers and users of hazardous materials.”

In written comments to ANSI on the upcoming revision to the consensus standard on preparing MSDSs, the CSB staff on August 22, 2003, recommended that ANSI incorporate a definition for combustible dust. However, on November 19, 2003, ANSI declined to do so, stating that OSHA had not yet incorporated the concept of combustible dusts into the Hazard Communication Standard.

Among the ten specific investigations cited in her testimony were these examples: MSDSs not provided to disposal site operators for flammable wastes that exploded in Texas; an explosion in New York City involving incompatible chemicals for which workers were provided no MSDSs; an explosion of a spent sulfuric acid tank in Delaware despite an MSDS that said of the spent sulfuric acid: “the product is not combustible.”

MSHA Urges Children to "Stay Out-Stay Alive" as National Public-Safety Campaign Begins Sixth Year

The U.S. Department of Labor's Mine Safety and Health Administration (MSHA) has begun its annual "Stay Out-Stay Alive" national public-safety campaign to warn children about the dangers of exploring and playing on mine property.

"Young people have a natural curiosity for the unknown," said Dave D. Lauriski, assistant secretary of labor for mine safety and health. "Unfortunately, old mines and quarries often are located in secluded places or in pristine settings, making them quite a temptation for those who like to explore the outdoors. Through this program, our goal is to warn kids and their parents about the potential hazards that exist on mine property, and to encourage them to find safer, supervised places to play."

Since 1999, more than 140 children and adults have died in recreational accidents at active and abandoned mine sites. For this reason, during the next two weeks MSHA personnel will deliver safety talks and distribute educational materials in schools throughout the country to educate children about the importance of steering clear of mine sites. To help publicize this effort, Lauriski recently talked to students at elementary schools in Albuquerque, N.M., and Rolla, Mo.

MSHA launched the "Stay Out-Stay Alive" program in 1999. Today, more than 80 federal and state agencies, private organizations, businesses and individuals are active partners in the campaign to make others aware of the approximately 14,000 active and nearly 500,000 abandoned mines in the United States. With towns spreading into the countryside, and more people visiting remote locations, this increases the possibility of public contact with active or abandoned mines.

These mines pose hazards, such as deep vertical shafts, horizontal openings supported by rotting timbers, unstable rock formations, and the presence of unused or misfired explosives. Water-filled quarries may conceal rock ledges and old machinery, and the water is often deceptively deep and dangerously cold. Old surface mines contain hills of loose materials in stockpiles or refuse heaps that can easily collapse and endanger others.