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

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• Physical marks (e.g., fire patterns) left by the fire. • Physical debris and damage, which indicated the direction and relative force of the explosions. • Observations reported by persons who witnessed the fire or explosions, or who were aware of conditions at the time. 7.1.1.1 Point of Origin CSB confirmed the conclusions of ATF and the State Fire Marshal that the fire and initial explosion originated at the line 405 oven. Based on eyewitness accounts and examination of physical evidence, CSB determined that the initial explosion’s point of origin was likely in the aisle on the east side of the line 405 oven, near the south end. A number of employees stated that they saw the initial flash at this location. The partially collapsed concrete block masonry firewall east of the oven also provided evidence of the location of the initial explosion. A metal cabinet along the wall had been knocked over and was found lying against the oven. In contrast, the west side of the oven received only fire damage rather than explosion damage. Also, burned resin deposits were on the exhaust hood located over the conveyor where the fiber mat enters the oven. Rolls of facing and empty spindles were burned but otherwise intact. The metal ducts that extended above the oven were warped and discolored—signs of extreme heat and external fire, but not explosion damage. CSB also examined the interior of the oven; virtually all the combustible material that likely had been inside was burned away (Figure 13). In contrast, the interior of the ovens on lines 401, 402, and 403 contained accumulations of resin powder/fiberglass debris. The chain-driven oven flights for 405 were 52
urned clean but otherwise intact and undamaged. Metal discoloration was noted on the interior of the line 405 oven; however, CSB found no evidence of explosion damage inside the oven. 7.1.1.2 Most Probable Initiating Event Figure 13. Interior of line 405 oven. CSB concluded that the most probable initiating event was a combustible dust explosion at the line 405 oven. Just prior to the explosion, the line crew cleared a blockage in the transition to the baghouse; this combustible material was dumped down a vertical pipe into a box on the blend room floor. Interviews with the crew revealed that dust was generated as the material landed in the box. A room fan mounted on the west wall of the blend room directed the combustible dust toward the oven. CSB determined that air currents probably transported the dust into the immediate area of the oven, where it likely ignited. A fire may have developed inside the oven as a result of a buildup of combustible material (Section 5.1.4). The oven had a history of small fires that were typically detected and put out by the line crew. In this case, the crew did not detect the fire because they were cleaning the line elsewhere. Flames may 53
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 and 38: panels and lights down inside the b
Page 39 and 40: occurred in the southeast corner of
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: 7.0 Reconstructive Analysis To dete
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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