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

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12.0 Root and Contributing Causes 12.1 Root Causes 1. CTA management did not implement effective measures to prevent combustible dust explosions. • Some managers discussed the explosion hazard of dust in the facility, but this information was not communicated to the general work force. • CTA did not obtain and use NFPA 654 as recommended in Borden Chemical’s phenolic resin MSDS. 2. The CTA cleaning and maintenance procedures for production lines did not prevent the accumulation of unsafe levels of combustible dust on elevated flat surfaces. • The use of metal tools, brooms, compressed air, and fans during line cleaning dispersed combustible dust in potentially explosive concentrations and also caused it to settle on elevated flat surfaces throughout the facility. • The housekeeping program did not effectively remove combustible dust that accumulated in areas above production lines. 3. The CTA incident investigation program did not ensure that all oven fires were investigated and that underlying causes were identified and resolved. CTA safety personnel estimated that oven fires occurred on an average of once a week. 90
4. The Borden Chemical product stewardship program did not explicitly convey to CTA the explosive hazards of phenolic resins. The Borden Chemical phenolic resin MSDSs noted that the phenolic resins were combustible dusts but did not explicitly warn that they could be explosive. Following the catastrophic explosion at the Jahn Foundry in 1999—which involved one of Borden Chemical’s phenolic resins—Borden Chemical did not enhance warnings on its MSDSs nor did it communicate the safety lessons of the Jahn investigation to CTA. 5. The CertainTeed building design and CTA building modifications did not effectively address the fire and explosion hazards associated with combustible dusts. The NFPA 654 standard on combustible dust safety only applied to the plastics industry in 1972; it did not cover operations such as CertainTeed’s. Nonetheless, following the building design principles contained in the standard could have prevented or mitigated the incident at CTA. Those principles include: • Minimizing flat surfaces to prevent accumulation of combustible dusts. • Installation of adequate firewalls and blast-resistant physical barriers and deflagration venting to prevent the spread of fire and explosive forces beyond the production area. CTA also did not use these principles when it made facility modifications. 12.2 Contributing Causes 1. The line 405 oven lacked fire detection devices and automatic sprinklers. NFPA 86, Standard for Ovens and Furnaces (2003), recommends evaluating the need to install automatic water sprinklers in ovens that accumulate appreciable quantities of combustible material. 91
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KEY ISSUES: U.S. CHEMICAL S AFETY A
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5.1.2 Line 405 Oven Temperature Con
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9.1 FM Global Guidelines...........
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Figures 1 Simplified Layout of CTA
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ACC American Chemistry Council Acro
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Executive Summary A February 20, 20
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1.0 Introduction At approximately 7
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2.0 Key Findings 1. Combustible phe
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3.0 Facility Description 3.1 CTA Ac
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eams. Nonload-bearing masonry block
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Thirteen-foot-high freestanding enc
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4.0 Process Description The product
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4.1.2 Mat-former and Baghouse In th
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Circulating fans and dampers direct
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• Manually striking baghouse bags
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5.0 Incident Description 5.1 Pre-In
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• The line was one week past due
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forklift with a semi-enclosed cab d
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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 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: 11.0 Combustible Dust Hazard Study
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
Page 109 and 110: 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
Page 119 and 120: 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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