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

• Excessive accumulations of combustible phenolic resin dust on flat surfaces fueled the fire
and explosions.
• A malfunctioning oven was involved.
• Housekeeping did not control excessive dust accumulations.
• Multiple secondary dust explosions caused fatalities, numerous burn injuries, and extensive
facility damage.
Borden Chemical did not communicate the safety lessons from this incident to CTA (Section 8.2.3.1).
CTA employees were not aware of the Jahn incident or the lessons learned from the investigation.
8.8.2 West Pharmaceutical Services
Three weeks prior to the CTA incident—on January 29, 2003—a dust fire and explosion occurred at West
Pharmaceutical Services in Kinston, North Carolina. Six workers died; at least 38 others, including two
firefighters, were injured. The facility produced rubber drug-delivery components for such items as
syringe plungers, septums, and vial seals.
CSB investigated this incident and found that the fuel for the fire and explosion was a combustible
polyethylene dust that had accumulated above a suspended ceiling over a manufacturing area. Similar to
the CTA incident, an initiating event disturbed the accumulated dust and started a cascade of secondary
dust explosions (USCSB, 2004). As a result of the West incident, the North Carolina Department of
Labor (2003) published an industry alert, entitled Combustible Dust Poses a Dangerous, Explosive Threat
in the Workplace.
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