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Bethlehem Steel Corporation Gas Condensate Fire

Overview

On February 2, 2001, a fire occurred at Bethlehem Steel Corporation's Burns Harbor mill in Chesterton, Indiana. One Bethlehem Steel millwright and one contractor supervisor died. Four Bethlehem Steel millwrights were injured, one seriously. Workers were attempting to remove a slip blind and a cracked valve from a coke oven gas line leading to a decommissioned furnace. During removal of the valve, flammable liquid was released and ignited.

Incident Snapshot

Field Value
Facility / Company Bethlehem Steel Corporation
Location Chesterton, IN
Incident Date 02/02/2001
Investigation Status The final report on this investigation was approved on December 6, 2001.
Accident Type Chemical Manufacturing - Fire and Explosion
Final Report Release Date 12/06/2001

What Happened

  • In 1992, the #4 batch furnace in the 160-inch plate mill was decommissioned, which created a deadleg in the COG piping.
  • Furnace demolition began in summer 2000.
  • On January 1, 2001, coke oven gas was found to be leaking from a crack in a 10-inch valve used to close off the COG line that fed the out-of-service #4 furnace.
  • The crack was likely caused by the freezing and expansion of water in COG condensate that had accumulated above the valve.
  • On January 5, millwrights installed a slip blind in the piping at the upper flange of the cracked valve to stop the leak.
  • This allowed liquid to again collect in the deadleg, which lacked a low point drain.
  • Upstream of the #4 furnace, pipe insulation was missing from condensate drain lines on the roof of the plate mill.
  • The missing insulation combined with freezing temperatures in December 2000 and January 2001 caused the drain lines to plug with ice, which prevented the removal of condensate from the COG piping.
  • It is most likely that flammable liquid concentrated and accumulated in the deadleg as the water trapped in the piping froze.
  • The inability to remove condensate also resulted in three incidents prior to February 2, including one on January 30, in which a large surge of fire and burning liquid were emitted from another furnace.
  • On Friday, February 2, millwrights were assigned to replace the blind and cracked valve with a blind flange and drain assembly.
  • A vacuum truck crew from Onyx Industrial Services was assigned to remove the condensate, which was expected to be non-flammable.
  • As the millwrights loosened and removed the bolts from around the blind, a small stream of liquid began to seep from the flange.
  • The valve and the slip blind suddenly dropped down several inches against the loosened bolts.
  • Flammable condensate sprayed out and soaked two of the millwrights and the Onyx supervisor.
  • The condensate ignited.
  • CSB identified an infrared heat lamp and a natural gas-fired space heater as two potential ignition sources.
  • As the flame reached the valve and the now open pipe, there was a blast and flammable liquid sprayed in all directions.
  • The two millwrights were engulfed in flames and fell behind the furnace structure.
  • One of these millwrights died; the other suffered burns and contusions.
  • The Onyx supervisor fell onto the demolition debris and was fatally burned.
  • In escaping through the flames, a third millwright received serious burns and another suffered smoke inhalation.

Facility and Process Context

  • Bethlehem Steel Corporation’s Burns Harbor mill is located in Chesterton, Indiana.
  • Burns Harbor opened in 1962.
  • The mill covers approximately 3 square miles.
  • The mill employs about 5,000 members of the United Steelworkers of America union and 1,100 salaried personnel.
  • There is a daily contractor population of 200 to 300.
  • Burns Harbor is an integrated mill that uses iron ore and coke to produce iron, which is converted to steel in three basic oxygen furnaces.
  • Coke is produced onsite from coal in two coke oven production units.
  • The 160-inch plate mill contains two continuous and four batch furnaces.
  • The batch furnaces are heated with either coke oven gas or natural gas.
  • The COG distribution system runs for several miles within the Burns Harbor facility.
  • The Burns Harbor mill’s winterization program for the plate mill consisted of a checklist of preventive measures for locations known to be susceptible to freezing, but it did not call for a survey or inspection to identify other areas that might require or might have lost freeze protection.

Consequences

  • Fatalities: 2 killed
  • Injuries: 4 injured, one seriously
  • Environmental release: Flammable condensate sprayed out and flammable liquid sprayed in all directions.
  • Facility damage: A fire occurred in the furnace area; the furnace structure had been demolished and a rubble/debris pile was present.
  • Operational impact: The furnaces were switched from coke oven gas to natural gas on January 1, 2001; the incident involved maintenance and valve removal work on February 2, 2001.

Key Findings

Immediate Causes

  • During removal of the valve, flammable liquid was released and ignited.
  • The condensate ignited.
  • As the flame reached the valve and the now open pipe, there was a blast and flammable liquid sprayed in all directions.

Contributing Factors

  • Missing pipe insulation caused water in the COG condensate to freeze and plug the system drains at the 160-inch plate mill in December 2000.
  • The condensate trapped in the COG piping separated into water and hydrocarbon layers.
  • As the water layer continued to freeze, liquid hydrocarbons accumulated in the COG piping and were carried into the furnace piping.
  • Three incidents in the 160-inch plate mill in January 2001 demonstrated that the amount of condensate in the COG system was unusually high and could be flammable.
  • The Burns Harbor facility did not have a system for monitoring and controlling hazards that could be caused by changes in COG condensate accumulation rates or flammability.
  • Knowledge of the previous incidents was not shared with the workforce performing the maintenance job on February 2.
  • The potential presence of flammables was not considered in job planning.
  • The installation of the slip blind created a hazardous situation; it allowed COG condensate to again accumulate in the deadleg and prevented safe draining of the line because there was no low point drain.
  • The demolition work at the #4 furnace was being conducted without sufficient planning, oversight, or control.
  • Demolition activities resulted in elevated walkways without railings and obstructed egress pathways, which prevented workers from quickly escaping when the ignition occurred.
  • The Burns Harbor facility did not have a program to identify and address hazards that might be created by decommissioning and demolition operations.

Organizational and Systemic Factors

  • Management systems for the supervision, planning, and execution of maintenance work were inadequate.
  • Burns Harbor mill personnel often bypassed the Lockout, Blue Flag, and Tag and Gas Hazard Control Program procedures when performing COG line maintenance in the steel handling areas of the facility.
  • Company requirements for written planning, job setup, and line isolation and purging were not followed on January 5 or February 2.
  • The work on January 5 and February 2 should not have been scheduled without a plan to control the hazards created by the potential for flammables and by the lack of a low point drain in the deadleg.
  • Personnel performing the work were not made aware of the possible presence of flammables, nor were they informed of the condensate incidents that occurred prior to February 2.
  • Obstructed exit routes due to demolition work on the #4 furnace were not considered during job planning.
  • Insulation was not reinstalled after the completion of maintenance work on an outdoor section of system piping.
  • The Burns Harbor facility did not have a system for monitoring and controlling hazards that could be caused by changes in COG condensate flammability or accumulation rates.
  • Changes in the amount of condensate being collected were not taken into account by management.
  • Employees were not generally aware of the potential flammability of COG condensate under certain operating conditions.
  • The Burns Harbor facility did not have a program to identify and address hazards that might be created by decommissioning and demolition operations.

Failed Safeguards or Barrier Breakdowns

  • The January 5 and February 2 jobs were conducted without a written purge procedure.
  • The Burns Harbor Lockout, Blue Flag, and Tag policy was not followed.
  • The line was not drained.
  • The slip blind eliminated the possibility of safely draining liquid that might accumulate in the deadleg.
  • No procedure was written for demolition of the furnace.
  • No safety review was conducted to consider the possible hazards created by the demolition activities.
  • No railing was in place on the east side of the walkway.
  • Piping from the demolition blocked the stairway landing to the walkway.
  • The stairway did not connect with the walkway.
  • Safety information was ineffectively transferred from management to the millwrights and contractors performing the maintenance work.
  • The millwrights and Onyx personnel stated that neither on January 5 nor February 2 were they informed of any flammables that might be present or of the previous incidents.
  • The Bethlehem Steel MSDS for COG condensate does not mention flammability as a hazard.
  • Neither the tanks nor the vacuum trucks were equipped with level or flow gauges to measure the amount of material transferred.
  • No actions were taken to investigate or correct the problem when condensate removal changed.

Recommendations

  1. 2001-02-I-IN-R1 — Recipient: Bethlehem Steel Corporation, Burns Harbor Mill — Status: Open — Implement a work authorization program that requires higher levels of management review, approval, and oversight for jobs that present higher levels of risk, such as opening lines potentially containing flammable liquids where there is no low point drain.
  2. 2001-02-I-IN-R2 — Recipient: Bethlehem Steel Corporation, Burns Harbor Mill — Status: Open — Monitor the accumulation and flammability of COG condensate throughout the mill. Address potentially hazardous changes in condensate accumulation rates and flammability.
  3. 2001-02-I-IN-R3 — Recipient: Bethlehem Steel Corporation, Burns Harbor Mill — Status: Open — Survey the mill for deadlegs and implement a program for resolving the hazards. Develop guidance for plant personnel on the risks of deadlegs and their prevention. Include deadlegs in plant winterization planning.
  4. 2001-02-I-IN-R4 — Recipient: Bethlehem Steel Corporation, Burns Harbor Mill — Status: Open — Provide drains at low points in piping to allow for the safe draining of potentially flammable material.
  5. 2001-02-I-IN-R5 — Recipient: Bethlehem Steel Corporation, Burns Harbor Mill — Status: Open — Ensure that Burns Harbor and contractor employees are trained with regard to the potential presence of flammable liquids when working with or opening COG or condensate piping and equipment.
  6. 2001-02-I-IN-R6 — Recipient: Bethlehem Steel Corporation, Burns Harbor Mill — Status: Open — Establish procedures to ensure that insulation is replaced when removed for maintenance.
  7. 2001-02-I-IN-R7 — Recipient: Bethlehem Steel Corporation — Status: Open — Conduct periodic audits of work authorization, line and equipment opening, deadleg management programs, and decommissioning and demolition activities at your steelmaking facilities. Share findings with the workforce.
  8. 2001-02-I-IN-R8 — Recipient: Bethlehem Steel Corporation — Status: Open — Revise the Material Safety Data Sheet (MSDS) for COG condensate to highlight the potential flammability hazard. Ensure that management at your steelmaking facilities trains employees and informs contractors with regard to the potential presence of flammable liquids when working with or opening COG condensate piping and equipment.
  9. 2001-02-I-IN-R9 — Recipient: Bethlehem Steel Corporation — Status: Open — Communicate findings of this report to the workforce and contractors at Bethlehem Steel’s steelmaking facilities.
  10. 2001-02-I-IN-R10 — Recipient: American Iron and Steel Institute, Association of Iron and Steel Engineers, United Steelworkers of America, AFL-CIO Building Trades Council — Status: Open — Communicate findings of this report to your membership.

Key Engineering Lessons

  • Deadlegs in coke oven gas piping can allow condensate to accumulate and create a flammable liquid hazard if no low point drain is provided.
  • Freeze protection for condensate drain lines must be maintained; missing insulation can allow ice plugging and prevent condensate removal.
  • Opening or removing valves and blinds on lines that may contain condensate requires written planning, purge/isolation controls, and verification that flammable material is not present.
  • Demolition and decommissioning work can create access and egress hazards that must be addressed in job planning before maintenance work is performed nearby.
  • Changes in condensate accumulation or behavior should trigger investigation and corrective action rather than being treated as expected non-flammable material.

Source Notes

  • All fields were consolidated from the final report, which has highest priority.
  • No conflicting higher-priority source was provided.
  • Terminology such as 'coke oven gas (COG)', 'deadleg', 'slip blind', and 'Lockout, Blue Flag, and Tag' was preserved from the source text.

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