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AL Solutions Fatal Dust Explosion

Overview

On December 9, 2010, a metal dust explosion and fire occurred at the AL Solutions, Inc. facility in New Cumberland, West Virginia. The incident resulted in three employee fatalities and one contractor injury. It also caused the shutdown of the plant. The CSB final report concluded that the explosion likely originated in a blender containing zirconium particulates. Metal-to-metal contact and possible hydrogen involvement were identified as contributing factors.

Incident Snapshot

Field Value
Facility / Company AL Solutions, Inc.
Location New Cumberland, WV
Incident Date 12/09/2010
Investigation Status The CSB's final report was approved 2-0 at a public meeting in Charleston, WV.
Accident Type Combustible Dust Explosion and Fire
Final Report Release Date 07/16/2014

What Happened

  • Around noon on the day of the incident, the day shift operators returned to work from lunch.
  • Two operators were running the three presses making titanium and zirconium compacts, and another operator was at the blender, mixing a batch of zirconium.
  • The shift supervisor was changing the mill blade in the adjacent milling room.
  • Three electrical contractors were also onsite, running conduit in a hydraulic room adjacent to the blending and press room.
  • At about 1:20 p.m., immediately before the explosion, an electrical contractor located about 6 feet outside a partially open door heard a loud noise described as a “metallic failure … like something popped … or fell.”
  • He then heard a “woof ... just how you’d light your gas grill” and “a big boom.”
  • The shift supervisor heard a loud bang and seconds later noticed an orange glow or flame coming from the blending and press room.
  • A second electrical contractor working in the hydraulic room heard an explosion in the neighboring blending and press room and then saw a fireball moving rapidly into the hydraulic room through the blending and press room door.
  • The third electrical contractor was in the restroom, where he heard “an angry noise,” felt a strong wind enter through a door, and then saw orange sparking flame at the ceiling.
  • The shift supervisor noticed the “air was sparking” after the explosion.
  • Employees in the main office building, who heard the explosion, called 911 to request emergency assistance.
  • The plant manager was walking from the warehouse to the production building at the time of the explosion and witnessed the event.
  • Some employees and contractors reported hearing a second explosion minutes after the initial explosion, which might have been caused by a propane tank rupture from a forklift inside the building.
  • The explosion and fire severely burned the zirconium press operator.
  • The supervisor, an electrical contractor, and the plant manager provided aid to the press operator until emergency personnel arrived.
  • Employees realized that two other operators were missing and presumably in the burning building.
  • A nearby volunteer firefighter heard the explosion and immediately proceeded to the scene.
  • The New Cumberland Volunteer Fire Department arrived minutes later.
  • At approximately 2:30 p.m., an airlift transported the injured contractor to a hospital.
  • By the time the VFD arrived, the building water deluge system had activated.
  • Firefighters attempted to access the building through the office, but the fire was too intense, and they could not enter.
  • Upon entering the original explosion area, firefighters discovered two deceased operators at the inside locations indicated in Figure 6.
  • The two operators in the blending and press room died at the scene, and the zirconium press operator died three days following the incident from severe burn injuries.
  • The explosion and subsequent fire caused minor blast damage to doors, walls, and interior windows as well as more substantial thermal damage throughout the production area.
  • The explosion caused thermal damage to the wall and overhead ceiling area adjacent to the blender.
  • Equipment damage included a lift truck, the blender, and the press feed conveyor.
  • The explosion propelled papers, desks, and lockers from the office into the parking lot outside of the production building.

Facility and Process Context

  • AL Solutions processes titanium and zirconium scrap metal into pressed compacts that aluminum producers use as alloy additives.
  • AL Solutions obtained scrap from titanium and zirconium manufacturers, and the end user adds the pressed compacts to furnaces or molten metal to increase the strength of aluminum alloys.
  • In 2006, AL Solutions purchased Jamegy, Inc., a metal producer based in New Cumberland, West Virginia.
  • At the time of the incident, AL Solutions owned and operated two processing facilities.
  • The primary office and production facility was located in New Cumberland, West Virginia.
  • AL Solutions also has a facility for milling in Washington, Missouri.
  • In 2010, AL Solutions employed 23 workers at the New Cumberland facility and two at the Washington facility.
  • The New Cumberland site lies on the east bank of the Ohio River in the Northern Panhandle of West Virginia, approximately 40 miles west of Pittsburgh, Pennsylvania.
  • The New Cumberland site contains a main production facility (now idle), warehouse, outside storage area, laboratory, and office area.
  • The New Cumberland production facility operated 24 hours a day, 7 days a week, and contained processing equipment for metal milling, blending, pressing, and water treatment.
  • Separated from the warehouse and office area by an access road, the production building was the site of the December 2010 explosion.
  • The main production building had a water deluge system that was set to activate upon detection of high temperatures or high concentrations of hydrogen gas.
  • Sensors located in the blender and press feed belt conveyor system would activate the deluge of water if readings reached a designated alarm point.
  • Operators also could manually activate the deluge system by turning a valve located in the blending and press room.
  • The New Cumberland facility had experienced two fatal explosions involving the ignition of metal dust before the 2010 incident.
  • From 1993 until the December 2010 incident, the New Cumberland VFD responded to at least seven fires at AL Solutions.
  • The AL Solutions milling facility in Missouri also had a fire that required a response from the local fire department.
  • Almost all employees reported that they had witnessed one or more fires in the production building.
  • AL Solutions continued to use a housekeeping approach as its principle means to minimize dust accumulations rather than adopting more robust engineering controls.

Consequences

  • Fatalities: 3
  • Injuries: 1 contractor injury
  • Environmental release: Not reported
  • Facility damage: The explosion and ensuing fire damaged the production building; minor blast damage to doors, walls, and interior windows; more substantial thermal damage throughout the production area; thermal damage to the wall and overhead ceiling area adjacent to the blender; equipment damage included a lift truck, the blender, and the press feed conveyor; papers, desks, and lockers were propelled from the office into the parking lot.
  • Operational impact: Ultimately caused the shutdown of the plant; production at the New Cumberland facility remains idle as a result of the 2010 incident; warehousing and office activities still take place at the facility.

Key Findings

Immediate Causes

  • The explosion likely initiated when particulates ignited in the blender that was processing zirconium.
  • Sparks or heat produced by metal-to-metal contact between the blender blades and the blender sidewall ignited the zirconium.
  • The cloud of combustible zirconium resulted in a deflagration.

Contributing Factors

  • The pre-explosion sound of metal failure or popping likely originated in the blender.
  • Residual burned zirconium was detected in the blender beneath the shaft.
  • Severe burn damage was also seen in the press on the other side of the production room.
  • There were indications of two adjacent cracks in one of the blender sidewalls.
  • Visual evidence of a burning dust cloud projected upward toward the ceiling.
  • Blender paddles were striking the sidewall of the blender and scoring the housing.
  • Maintenance personnel adjusted the blender blades to increase clearance from the blender wall, but this action did not permanently address the issue with the metal-to-metal contact.
  • A maintenance worker welded a crack in the blender sidewall, and operators continued to use the blender.
  • A worn paddle was replaced about two hours before the incident.
  • AL Solutions did not repair or replace the blender to avoid exposing combustible metal dusts to sparks or heat produced by the mechanical impact from the paddles.
  • The blender likely contained a substantial quantity of zirconium.
  • Burning zirconium particulates lofted from the blender after the initial explosion, engulfing the room in fire.
  • The blender lid was found left in the open position.
  • The burning zirconium dust cloud also ignited open drums and tubs of titanium and zirconium at several locations in the production building, propagating the fire.
  • The hydrogen gas produced by the reaction of molten titanium or zirconium metal and water, possibly from wash-down operations or the water deluge system, may have also contributed to the explosion.
  • AL Solutions did not have a ventilation system to control hydrogen concentrations.
  • Natural ventilation was inconsistent in the production building; employees reported closing rollup doors for temperature control during the cold months.
  • AL Solutions did not use a dust collection system to remove zirconium and titanium dusts generated during processing.
  • AL Solutions instead relied on the use of water as the only method to eliminate dust fires and explosions by keeping dust moist and avoiding dust accumulation on equipment and flat surfaces.
  • The facility was not equipped with Class D fire extinguishers appropriate for fighting metal fires.
  • The company instructed its personnel to let metal fires burn and wait for the fire department.
  • The West Virginia Area Office of OSHA did not conduct a Combustible Dust NEP inspection at AL Solutions before the 2010 incident, despite the company’s history of metal dust incidents.
  • The next steps of the OSHA rulemaking process for promulgating a general industry combustible dust standard have been delayed.

Organizational and Systemic Factors

  • AL Solutions employees were generally aware that the metal dust was combustible and that a spark on the metal could cause a fire.
  • The AL Solutions safety manual listed several requirements for safe storage and handling of titanium and zirconium, but management did not enforce these requirements.
  • Management did not enforce the practice of leaving lids closed whenever possible to isolate the equipment and prevent dispersion of dust.
  • AL Solutions employees commonly left barrels of titanium and zirconium in the production building, even if they were not in use.
  • AL Solutions also did not enforce industrial hygiene practices related to handling metal dusts.
  • Management did not enforce the requirement to use a high-efficiency particulate respirator when handling the materials.
  • AL Solutions management had procedures in place to remove dust and to control fire and explosion hazards at the facility.
  • Operators used spark-resistant tools and wore 100 percent cotton clothes.
  • No open flames were allowed in the production building, and all smoking was restricted to an area outside the break room.
  • AL Solutions regularly washed down the equipment with water as its primary means to eliminate dust from process equipment and areas.
  • Operators washed metal powder to the floor and then into troughs that ran along the floor of the production building, and they cleaned these troughs weekly.
  • AL Solutions did not use a dust collection system.
  • The AL Solutions safety manual instructed operators to evacuate the building, alert management, and call the fire department in the event of a metal fire.
  • The AL Solutions Emergency Plan recommended that employees avoid fighting metal dust fires with fire extinguishers.
  • The facility was not equipped with Class D fire extinguishers appropriate for fighting metal fires.
  • The company instructed its personnel to let metal fires burn and wait for the fire department.
  • Facility safety and insurance audits did not adequately identify and address metal dust hazards at the New Cumberland facility.
  • The 2008 audit commended the facility on its “wet process producing no dust.”
  • The 2009 audit declared that incidents are effectively controlled by “good housekeeping,” “established raw material storage practices,” and “water added during manufacturing process to control dust.”
  • Neither of the insurance audits made any recommendations to AL Solutions that it should change its process design or dust management systems.
  • The insurance audits did not reference industry consensus standards for dust, such as NFPA 484.
  • A comprehensive process hazard analysis was not recommended or performed despite the hazardous nature of the process and despite previous incidents.
  • Management did not mitigate the hazards of metal dust explosions through engineering controls, such as a dust collection system.
  • AL Solutions did not adhere to the practices recommended in NFPA 484 for controlling combustible metal dust hazards.
  • The operators, supervisors, and engineers at AL Solutions were not familiar with NFPA 484.
  • The process design, construction, and fire prevention practices did not consider the provisions of the NFPA standard.
  • AL Solutions stated that they implemented the recommendations, but were not responsive to multiple requests over the course of five years to provide documentation demonstrating the actions that were taken.

Failed Safeguards or Barrier Breakdowns

  • The blender and the press conveyor had metal lids, and the plan was to leave the lids closed whenever possible to isolate the equipment and prevent dispersion of dust; the blender, conveyor belt lid, and storage drums were regularly left open during operation.
  • AL Solutions did not use a dust collection system to remove zirconium and titanium dusts generated during processing.
  • The facility was not equipped with Class D fire extinguishers appropriate for fighting metal fires.
  • The water deluge system was used as the method to extinguish a metal dust fire despite warnings in NFPA 484 and the MSDSs.
  • Maintenance did not adequately address the metal-to-metal contact that was the likely ignition source for the 2010 explosion.
  • The blender lid was found left in the open position.
  • The West Virginia Area Office of OSHA did not conduct a Combustible Dust NEP inspection at AL Solutions before the 2010 incident.
  • Neither the State Fire Marshal nor the New Cumberland VFD inspected the AL Solutions facility to ensure compliance with the State Fire Code or with NFPA 484.
  • The State Fire Marshal performed an investigation after the 2006 incident but issued no recommendations and did not require the facility to follow NFPA 484.

Recommendations

  1. 2006-1-H-1 | Recipient: Occupational Safety and Health Administration | Status: Open | Summary: Issue a standard designed to prevent combustible dust fires and explosions in general industry. Base the standard on current National Fire Protection Association (NFPA) dust explosion standards (including NFPA 654 and NFPA 484), and include at least hazard assessment, engineering controls, housekeeping, building design, explosion protection, operating procedures, and worker training.
  2. 2011-3-I-WV R1 | Recipient: AL Solutions, Inc. | Status: Open | Summary: For all new and existing equipment and operations at AL Solutions facilities that process combustible metal dusts or powders, apply the following chapters of NFPA 484-2012, Standard for Combustible Metals: Chapter 12, Titanium; Chapter 13, Zirconium; Chapter 15, Fire Prevention, Fire Protection, and Emergency Response; Chapter 16, Combustible Metal Recycling Facilities.
  3. 2011-3-I-WV R2 | Recipient: AL Solutions, Inc. | Status: Open | Summary: Develop training materials that address combustible dust hazards and plant-specific metal dust hazards and then train all employees and contractors. Require periodic annual refresher training for all employees and contractors.
  4. 2011-3-I-WV R3 | Recipient: AL Solutions, Inc., Facility in Burgettstown, Pennsylvania | Status: Open | Summary: Prohibit the use of sprinkler systems and water deluge systems in all buildings that process or store combustible metals.
  5. 2011-3-I-WV R4 | Recipient: AL Solutions, Inc., Facility in Burgettstown, Pennsylvania | Status: Open | Summary: Conduct a process hazard analysis as defined in NFPA 484-2012, Section 12.2.5, and submit a copy to the local fire department or the enforcing authority for the fire code.

Key Engineering Lessons

  • Metal-to-metal contact in rotating process equipment can be an ignition source for combustible metal dusts and must be controlled by design and maintenance.
  • Combustible metal dust hazards at titanium and zirconium processing facilities require engineering controls rather than reliance on housekeeping and water alone.
  • Dust collection and hydrogen control systems are important where processing can generate combustible dusts and hydrogen gas.
  • Equipment and process design should consider NFPA 484 provisions for combustible metals, including fire prevention, fire protection, and emergency response.
  • Leaving lids open during operation can defeat isolation intended to prevent dust dispersion and increase explosion and fire propagation potential.

Source Notes

  • Priority 1 final report was used as the primary authority for incident facts, causes, and findings.
  • Priority 4 transcript and recommendation status page were used only to supplement or confirm final report information and recommendation status.
  • Where the transcript and final report differed in wording, the final report terminology was preferred.
  • No external facts were added beyond the provided source extracts.

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