Combustible Dust Hazard Investigation

Overview

CSB Combustible Dust Hazard Study (Report No. 2006-H-1) identified 281 combustible dust incidents between 1980 and 2005 that killed 119 workers and injured 718. The study was prompted by three catastrophic 2003 dust explosions in North Carolina, Kentucky, and Indiana that killed 14 workers and injured 81. The report concluded that combustible dust explosions are a serious hazard in American industry and that existing efforts inadequately address the hazard.

Incident Snapshot

Field	Value
Facility / Company	Not specified; multi-incident CSB study
Location	Washington, DC
Incident Date	10/01/2004
Investigation Status	The CSB issued its final report at a public meeting in Washington, DC, on November 9, 2006, calling for a new OSHA regulatory standard designed to prevent combustible dust fires and explosions.
Accident Type	Combustible Dust Explosion and Fire Investigation
Final Report Release Date	11/09/2006

What Happened

Following three catastrophic dust explosions that killed 14 workers in 2003, the CSB initiated a study of dust explosions in general industry.

On January 29, 2003, a massive dust explosion at the West Pharmaceutical Services facility in Kinston, North Carolina, killed six workers and destroyed the facility.

On February 20, 2003, a series of dust explosions at the CTA Acoustics facility in Corbin, Kentucky, claimed the lives of seven workers, injured 37, and destroyed the manufacturing facility.

On October 29, 2003, aluminum dust exploded at the Hayes Lemmerz International facility in Huntington, Indiana, killed one worker and injured several others.

The CSB issued its final report at a public meeting in Washington, DC, on November 9, 2006.

Facility and Process Context

• West Pharmaceutical Services facility in Kinston, North Carolina
• CTA Acoustics facility in Corbin, Kentucky
• Hayes Lemmerz International facility in Huntington, Indiana
• The study focused on general industry facilities handling combustible powders and dusts.
• The study excluded grain-handling facilities regulated by OSHA's grain handling standard, coal mines and MSHA-covered facilities, coal dust at power generation plants, non-manufacturing facilities, transportation, and incidents outside the United States or U.S. territories.

Consequences

• Fatalities: 119 workers in 281 incidents between 1980 and 2005; 14 individuals were killed in the three 2003 catastrophic dust explosions; West Pharmaceutical Services killed six workers; CTA Acoustics claimed the lives of seven workers; Hayes Lemmerz killed one worker.
• Injuries: 718 workers in 281 incidents between 1980 and 2005; 81 injured in the three 2003 catastrophic dust explosions; West Pharmaceutical Services injured 38 others; CTA Acoustics injured 37; Hayes Lemmerz injured several others.
• Environmental release: Not reported.
• Facility damage: Destroyed the West Pharmaceutical Services facility; destroyed the CTA Acoustics manufacturing facility; extensive property losses and damage across multiple incidents.
• Operational impact: The incidents occurred in 44 states, in many different industries, and involved a variety of different materials.

Key Findings

Immediate Causes

• polyethylene powder accumulated on surfaces above the suspended ceiling, providing fuel for a devastating secondary explosion
• a curing oven that had been left open because of a temperature control problem likely ignited the combustible resin dust stirred up by workers cleaning the area near the oven
• the explosion likely originated in the dust collector
• the deflagration of polyethylene powder that had accumulated above a suspended ceiling in the processing area of the facility
• the explosion began near a curing oven, where routine cleaning lofted accumulated resin dust that was ignited by fire in an oven on which the doors were left open

Contributing Factors

• Workers and managers were often unaware of dust explosion hazards, or failed to recognize the serious nature of dust explosion hazards.
• Facility management failed to conform to NFPA standards that would have prevented or reduced the effects of the explosions.
• The facilities contained unsafe accumulations of combustible dust and housekeeping was inadequate.
• Procedures and training to eliminate or control combustible dust hazards were inadequate.
• Warning events were accepted as normal and their causes were not identified and resolved.
• Dust collectors were inadequately designed or maintained to minimize explosions.
• Process changes were made without adequately reviewing them for the introduction of new potential hazards.
• Government enforcement officials, insurance underwriters, and health and safety professionals inspecting the facilities failed to identify dust explosion hazards.
• The dust explosion hazard was not addressed during the reviews.
• The building was not designed to prevent or minimize secondary dust explosions.
• Dust had accumulated in dangerous amounts throughout the production areas, in vent ducting, and in dust collector housings, due to inadequate housekeeping and maintenance.
• Employees routinely used compressed air and brooms to clean production lines, creating clouds of resin dust.
• The dust collector system was not designed or maintained to prevent dust explosions, or to prevent a dust collector explosion from spreading through ducting.
• Hayes had also not cleaned dust from overhead beams and other structures.
• Previous dust fires at the facility were not investigated.
• routine cleaning lofted accumulated resin dust
• the doors were left open
• ineffective management of change
• hazard awareness
• regulatory oversight
• effectiveness of fire code enforcement
• many MSDSs do not communicate the potential hazards of materials that may generate combustible dust as a result or byproduct of processing

Organizational and Systemic Factors

• no comprehensive federal Occupational Safety and Health Administration (OSHA) standard exists to control the risk of dust explosions in general industry
• the adoption and enforcement of NFPA standards in state and local fire codes is inconsistent and largely ineffective
• local fire code enforcement officials rarely inspect industrial facilities
• fire code officials focus primarily on life-safety issues such as sprinklers, extinguishers, and fire escapes, rather than on industrial hazards such as combustible dust
• local fire code officials—as well as other health and safety professionals—are often unfamiliar with combustible dust hazards
• OSHA combustible dust citations have relied on the General Duty Clause (Section 5(a)(1)) or a variety of OSHA standards only tangentially related to dust explosion hazards
• MSDSs generally fail to effectively communicate to employers and workers necessary information about combustible dust hazards or ways to prevent them
• OSHA’s Hazard Communication Standard (HCS) does not clearly state that it applies to combustible dusts
• the ANSI standard does not explicitly address combustible dusts, define combustible dust, or describe the need to address the potential explosion hazards associated with combustible dusts
• the GHS, like the OSHA HCS and ANSI Z400.1, inadequately addresses the explosion potential of combustible dusts
• training programs for OSHA compliance officers and fire code inspectors generally do not address recognizing combustible dust hazards
• CSB found that issues related to hazard awareness, regulatory oversight, and effectiveness of fire code enforcement were common to these three accidents.
• CSB has found that awareness about combustible dust hazards throughout industry, including occupational health and safety professionals, is generally low.
• CSB has found that the primary regulatory mechanism for controlling or eliminating combustible dust hazards is enforcement of fire codes by local fire code officials.

Failed Safeguards or Barrier Breakdowns

• NFPA standards for combustible dust
• housekeeping
• training
• management of change procedures
• dust collector design and maintenance
• explosion venting
• electrical equipment rated for use around combustible dust
• fire code inspections
• OSHA inspections
• MSDS warnings
• Hazard Communication Standard
• ANSI Z400.1
• GHS guidance
• fire code enforcement
• Material Safety Data Sheets for materials that may form combustible dusts did not adequately communicate explosion hazards
• inspections by insurers had not identified combustible dust hazards

Recommendations

1. Recommendation 1 — Recipient: Occupational Safety and Health Administration (OSHA) — 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. Recommendation 2 — Recipient: Occupational Safety and Health Administration (OSHA) — Status: Open — Summary: Revise the Hazard Communication Standard (HCS) (1910.1200) to clarify that the HCS covers combustible dusts, including those materials that may reasonably be anticipated to generate combustible dusts through downstream processing or handling, and require Material Safety Data Sheets (MSDSs) to include the hazards and physical properties of combustible dusts, as well as clear information on safe handling practices and references to relevant consensus standards.
3. Recommendation 3 — Recipient: Occupational Safety and Health Administration (OSHA) — Status: Open — Summary: Communicate to the United Nations Economic Commission for Europe (UNECE) the need to amend the Globally Harmonized System (GHS) to address combustible dust hazards by defining combustible dusts, specifying the hazards that must be addressed in chemical information sheets, and addressing the physical properties that must be included on a chemical information sheet pertinent to combustible dusts.
4. Recommendation 4 — Recipient: Occupational Safety and Health Administration (OSHA) — Status: Open — Summary: Provide training through the OSHA Training Institute (OTI) on recognizing and preventing combustible dust explosions.
5. Recommendation 5 — Recipient: Occupational Safety and Health Administration (OSHA) — Status: Open — Summary: While a standard is being developed, identify manufacturing industries at risk and develop and implement a national Special Emphasis Program (SEP) on combustible dust hazards in general industry. Include in the SEP an outreach program focused on the information in the Safety and Health Information Bulletin (SHIB), Combustible Dust in Industry: Preventing and Mitigating the Effects of Fire and Explosions.
6. Recommendation 6 — Recipient: American National Standards Institute Z400.1 Committee — Status: Open — Summary: Modify ANSI Z400.1 American National Standard for Hazardous Industrial Chemicals--Material Safety Data Sheets to recommend that MSDSs include information on combustible dust hazards, safe handling practices, and references to relevant fire codes in MSDS; hazard information about the by-products of materials that may generate combustible dusts due to processing or handling; identification of combustible dust hazards and selection of physical properties to include in MSDS.

Key Engineering Lessons

• Combustible dust accumulations above suspended ceilings, in ducting, and in dust collector housings can fuel devastating secondary explosions.
• Dust collector systems must be designed and maintained to prevent explosions and to prevent propagation through ducting.
• Routine cleaning methods that loft dust, such as compressed air and brooms, can create hazardous dust clouds.
• Open or malfunctioning process equipment, such as curing ovens, can provide ignition sources for dispersed combustible dust.
• Housekeeping, building design, and explosion protection are critical controls for preventing or reducing the effects of dust explosions.
• NFPA dust explosion standards were identified as comprehensive and effective when applied.

Source Notes

• Priority 1 final report used as the authoritative source for incident findings and recommendations.
• Supporting documents were used only to supplement context where consistent with the final report.
• No facility company name was identified for the overall study incident; the dataset reflects a multi-incident CSB study rather than a single facility event.
• The incident date and location reflect the crawler metadata for the study/publication record, not a single plant accident.

Reference Links

• CSB Combustible Dust Hazard Investigation

Similar Incidents

Incidents sharing the same equipment, root causes, or hazard types.

Same Equipment

• CTA Acoustics Dust Explosion and Fire — Shared equipment: Dust Collector · Oven
• Hayes Lemmerz Dust Explosions and Fire — Shared equipment: Dust Collector · Furnace
• Didion Milling Company Explosion and Fire — Shared equipment: Dryer · Dust Collector
• Imperial Sugar Company Dust Explosion and Fire — Shared equipment: Dust Collector · Screw Conveyor

Same Root Cause

• Didion Milling Company Explosion and Fire — Shared failure mode: Communication Failure · Design Deficiency · Housekeeping Failure · Ignition Source Control Failure · Inspection Failure · Management Of Change Failure · Training Deficiency
• West Pharmaceutical Services Dust Explosion and Fire — Shared failure mode: Communication Failure · Design Deficiency · Housekeeping Failure · Ignition Source Control Failure · Management Of Change Failure · Training Deficiency
• Packaging Corporation of America Hot Work Explosion — Shared failure mode: Communication Failure · Design Deficiency · Ignition Source Control Failure · Management Of Change Failure · Training Deficiency
• AL Solutions Fatal Dust Explosion — Shared failure mode: Design Deficiency · Housekeeping Failure · Ignition Source Control Failure · Inspection Failure · Training Deficiency
• Bethune Point Wastewater Plant Explosion — Shared failure mode: Communication Failure · Design Deficiency · Ignition Source Control Failure · Inspection Failure · Training Deficiency

Same Hazard

• AL Solutions Fatal Dust Explosion — Shared hazard: Dust Explosion · Explosion · Fire
• CTA Acoustics Dust Explosion and Fire — Shared hazard: Dust Explosion · Explosion · Fire
• US Ink Fire — Shared hazard: Dust Explosion · Explosion · Fire
• Imperial Sugar Company Dust Explosion and Fire — Shared hazard: Dust Explosion · Explosion · Fire
• West Pharmaceutical Services Dust Explosion and Fire — Shared hazard: Dust Explosion · Explosion · Fire

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