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

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2. CTA did not have effective procedures for evaluating the hazards associated with nonroutine operating conditions on line 405. Operating the oven with malfunctioning temperature control equipment and open doors was a nonroutine situation—the hazards of which were not recognized or controlled. 92
13.0 Recommendations CSB developed the following recommendations from the findings and conclusions of this investigation. Recommendations are made to parties that can effect change to prevent future incidents. Those parties typically include the facility where the incident occurred, the parent company, trade organizations responsible for developing good practice guidelines, or organizations that have the ability to broadly communicate lessons learned from the incident—such as trade associations and labor unions. CTA Acoustics, Inc. 1. Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum: • Minimize surfaces where combustible dust could accumulate in the design or modification of the plant. (2003-09-I-KY-R1) • Ensure phenolic resin-handling facilities are designed to prevent the spread of fires or explosions involving combustible dust. Options include measures such as the use of firewalls and blast-resistant construction. (2003-09-I-KY-R2) • Prevent the unsafe accumulation and dispersion of combustible dust by frequently cleaning process areas, including locations above production lines. (2003-09-I-KY-R3) • Minimize the dispersion of combustible dust by using appropriate dust-cleaning methods and tools. (2003-09-I-KY-R4) • Address the dangers of combustible dust and the prevention of dust explosions in the hazard communication training program. (2003-09-I-KY-R5) 93
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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
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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 and 90: 11.0 Combustible Dust Hazard Study
Page 91: 4. The Borden Chemical product stew
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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