CTA Report, Draft 1, ISP Review - US Chemical Safety and Hazard ...

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Figure 7. Collapsed firewall between lines 403 and 405. When the fireball reached line 403, it moved into the blend room. Three operators and the shift supervisor received second- and third-degree burns from the fireball and were transported to hospital burn units; they died days later. Two other operators were also burned, one critically. Operators working on the roof of the plant observed the line 403 baghouse catch on fire. The cleanout doors opened on line 403 equipment may have provided a path for flames to travel to that baghouse. 5.2.5 Fire at Line 402 After the pressure wave from the second dust explosion blew in the metal panels above the line 403 blend room, the fireball following it continued to move west and into line 402. Three operators were burned in the blend room or aisle that separated lines 403 and 402 (Figure 5). They were transported to the hospital; two of these men later died. 5.2.6 Fire and Additional Dust Explosion at Line 401 The fireball continued to move west over the top of the line 402 blend room and into line 401. CSB investigators noted extensive explosion damage at line 401, nearly 300 feet from the initial explosion’s point of origin at line 405. Physical evidence revealed that an additional secondary dust explosion 38
occurred in the southeast corner of the line 401 blend room, another confined area. The firewall south of line 401 was partially collapsed, and concrete blocks dislodged from this wall fell to the south. The force of the dust explosion pressure wave likely bent a steel column on the west side of the blend room (Figure 8). Metal panels of the north and west walls were deformed outward. A large hole was blown in the building roof above the southeast corner of the blend room. Figure 8. Bent support column in line 401 blend room. Line 416 operators observed a fireball traveling north toward them from the line 401 blend room. They stated that the fireball receded when it reached the end of the line 401 oven. Still, the effects of the pressure wave that accompanied the fireball knocked some of them down. That wave vented out of the building at the northwest corner, where it damaged a loading dock door. It also blew out portions of the plant’s metal panel west wall (Figure 9) and damaged the north wall of the chemical room, located near the southwest corner of the plant. At the time of the secondary dust explosions, line 401 had been running for a few minutes. Three operators at this location were severely burned (Figure 5); they received extended treatment from the hospital. Two other operators received minor injuries. 39
Page 1 and 2: KEY ISSUES: U.S. CHEMICAL S AFETY A
Page 3 and 4: 5.1.2 Line 405 Oven Temperature Con
Page 5 and 6: 9.1 FM Global Guidelines...........
Page 7 and 8: Figures 1 Simplified Layout of CTA
Page 9 and 10: ACC American Chemistry Council Acro
Page 11 and 12: Executive Summary A February 20, 20
Page 13 and 14: 1.0 Introduction At approximately 7
Page 15 and 16: 2.0 Key Findings 1. Combustible phe
Page 17 and 18: 3.0 Facility Description 3.1 CTA Ac
Page 19 and 20: eams. Nonload-bearing masonry block
Page 21 and 22: Thirteen-foot-high freestanding enc
Page 23 and 24: 4.0 Process Description The product
Page 25 and 26: 4.1.2 Mat-former and Baghouse In th
Page 27 and 28: Circulating fans and dampers direct
Page 29 and 30: • Manually striking baghouse bags
Page 31 and 32: 5.0 Incident Description 5.1 Pre-In
Page 33 and 34: • The line was one week past due
Page 35 and 36: forklift with a semi-enclosed cab d
Page 37: panels and lights down inside the b
Page 41 and 42: 5.3.3 Firefighting Activities 5.3.3
Page 43 and 44: 5.4 Incident Aftermath The CTA inci
Page 45 and 46: 6.0 Understanding Combustible Dust
Page 47 and 48: As depicted in Figure 11 (Eckhoff,
Page 49 and 50: Figure 12. Mechanism for a dust fir
Page 51 and 52: 7.0 Reconstructive Analysis To dete
Page 53 and 54: urned clean but otherwise intact an
Page 55 and 56: 7.1.2 Other Possible Initiating Eve
Page 57 and 58: Table 3 Borden Chemical Black Pheno
Page 59 and 60: 7.3 Line 405 Equipment Testing CSB
Page 61 and 62: determine if those products are haz
Page 63 and 64: that the phenolic resin could explo
Page 65 and 66: A 1998 internal Borden Chemical mem
Page 67 and 68: • Characterize new and existing p
Page 69 and 70: CTA that phenolic resins, when susp
Page 71 and 72: CTA department supervisors were res
Page 73 and 74: 8.5 Work Practices 8.5.1 Production
Page 75 and 76: operating the oven with the doors o
Page 77 and 78: 8.7 Incident Investigations The inc
Page 79 and 80: • Excessive accumulations of comb
Page 81 and 82: Data Sheet 6-9 also states: Clean o
Page 83 and 84: Table 5 Insurance Company Dust Issu
Page 85 and 86: standards (Appendix D). Kentucky OS
Page 87 and 88: 10.2.2 Division of Building Codes E
Page 89 and 90:
11.0 Combustible Dust Hazard Study
Page 91 and 92:
4. The Borden Chemical product stew
Page 93 and 94:
13.0 Recommendations CSB developed
Page 95 and 96:
Kentucky Office of Occupational Saf
Page 97 and 98:
BY THE U.S. Chemical Safety and Haz
Page 99 and 100:
Lawson, Robert G., 1984. Beverly Hi
Page 101 and 102:
APPENDIX A: Fire and Explosion Dama
Page 103 and 104:
APPENDIX B: Laboratory Testing of P
Page 105 and 106:
B.2 Minimum Explosible Concentratio
Page 107 and 108:
B.4 Propagating Brush Discharge Ign
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Material Corona Charge Voltage (kV)
Page 111 and 112:
APPENDIX C: Equipment Testing Line
Page 113 and 114:
II controllers, only manufactured a
Page 115 and 116:
Therefore, at any given time, it wa
Page 117 and 118:
APPENDIX D: NFPA Guidelines In prom
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D.2 Other Pertinent NFPA Codes D.2.
Page 121 and 122:
APPENDIX E: HMIS Rating System The
Page 123 and 124:
APPENDIX F: Simplified Organization
Page 125 and 126:
Subtree A Second dust explosion abo
Page 127:
Subtree C Most CTA personnel had a
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