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West Fertilizer Explosion and Fire

Overview

On April 17, 2013, a fire and explosion occurred at the West Fertilizer Company (WFC), a fertilizer blending, retail, and distribution facility in West, Texas. The violent detonation fatally injured 12 emergency responders and three members of the public, injured more than 260 people, destroyed the facility, and caused widespread offsite damage.

Incident Snapshot

Field Value
Facility / Company West Fertilizer Company (WFC)
Location West, TX
Incident Date 04/17/2013
Investigation Status The CSB's investigation was approved by a unanimous board vote at a public meeting in Waco, TX, on January 28, 2016.
Accident Type Chemical Distribution - Fire and Explosion
Final Report Release Date 01/28/2016

What Happened

  • On April 17, 2013, at approximately 7:29 pm, citizens reported signs of smoke and fire at the West Fertilizer Company (WFC) facility to the local 911 dispatch center.
  • Emergency dispatchers paged the West Volunteer Fire Department (WVFD), and firefighters responded to the scene.
  • According to eyewitness accounts, the fire intensified very quickly and was described as a rolling fire that moved from the northeast end of the fertilizer building toward the southern end of the building.
  • At approximately 7:51 pm, a massive explosion occurred.
  • The blast completely destroyed the WFC facility and caused widespread damage to more than 150 offsite buildings.

Facility and Process Context

  • The WFC stored and distributed fertilizers, chemicals, grains, and various other farming supplies.
  • The fertilizer building was a wood-framed structure with a concrete floor and was constructed piecemeal over the years, starting with the original construction in 1961.
  • FGAN was stored in two plywood bins along the west wall of the building and in one primary FGAN bin at the north end of the building.
  • The WFC facility had two 12,000-gallon anhydrous ammonia storage vessels, located to the south of the fertilizer building, for distribution and sale of the product to farmers.
  • Adjacent to the anhydrous ammonia tanks, liquid fertilizer was stored outside in several vertical tanks.
  • The WFC facility had a history of intermixing and cross-contamination during unloading because no cleaning process was used to clear the conveyor belt before the next load was transferred.
  • The WFC used air conditioning to cool and remove moisture from the primary FGAN bin.

Consequences

  • Fatalities: 15 people were killed; 12 emergency responders and three members of the public.
  • Injuries: More than 260 injured victims.
  • Environmental release: The document states that the FGAN explosion damaged the facility’s anhydrous ammonia tanks; if more force had been applied to the tanks, their contents could have been released into the neighboring community.
  • Facility damage: The blast completely destroyed the WFC facility and caused widespread damage to more than 150 offsite buildings.
  • Operational impact: WFC filed for bankruptcy.

Key Findings

Immediate Causes

  • The first observed fire and smoke originated in and above the seed room and progressed throughout the northern half of the WFC facility.
  • The fire spread to FGAN storage piles and nearby combustibles.
  • The FGAN explosion at the WFC facility.

Contributing Factors

  • The storage of combustible materials near FGAN storage piles and the use of combustible bins likely facilitated the spread of the FGAN-related fire to other bins and nearby combustibles.
  • The wood-constructed bins likely contaminated the AN, ultimately leading to the detonation by increasing AN energy and sensitivity.
  • The radiant heat from the fire, fueled by the structure, flammable building contents, and the asphalt roof shingles, likely heated the surface of the FGAN pile.
  • Contamination from soot, molten asphalt, and molten polyvinyl chloride (PVC) from an overhead conveyer produced a detonable mixture of combustibles and FGAN oxidizers.
  • Increased ventilation generated a brighter and hotter flame, heating the FGAN-fuel mixture on the surface of the pile.
  • The WFC facility had a history of intermixing and cross-contamination during unloading because no cleaning process was used to clear the conveyor belt before the next load was transferred.
  • The WFC used fans to control the dust during unloading, and on some occasions, workers added a vegetable oil coating to the ammonium phosphate to reduce the dust.
  • The WFC used air conditioning to cool and remove moisture from the primary FGAN bin.
  • The WFC never completely filled the primary bin to avoid another failure after the northeast corner of the north wall of the primary FGAN bin failed about 2 years before the explosion.
  • The location of the WFC relative to the surrounding community exacerbated the offsite consequences.
  • The city of West had a history of improperly working water hydrants and consistently low water pressure.

Organizational and Systemic Factors

  • The West Volunteer Fire Department did not conduct pre-incident planning or response training at WFC, was likely unaware of the potential for FGAN detonation, did not take recommended incident response actions at the fire scene, and did not have appropriate training in hazardous materials response.
  • CSB found no evidence of pre-incident planning addressing the likelihood of a fire involving FGAN at the WFC facility.
  • The current training resources at the local, state, and federal levels do not provide sufficient information for firefighters to understand the hazards of FGAN.
  • Texas had no state fire code at the time of the incident and still had no such code as of publication of the report.
  • The WFC facility was not listed in McLennan County LEPC Annex Q.
  • The WFC did not submit Top-Screen information to DHS as required under CFATS.
  • The WFC qualified under OSHA’s interpretation of the PSM retail facilities exemption.
  • The WFC was not required to conduct facility siting because it qualified for the PSM standard’s retail facilities exemption.
  • The WFC facility did not have a fire detection system or an automatic sprinkler system.
  • The WFC was dropped by one insurer for failing to address safety concerns identified in loss control surveys.
  • The company that insured WFC at the time of the incident did not appear to have conducted its own safety inspections of the facility.

Failed Safeguards or Barrier Breakdowns

  • lack of an automatic sprinkler system
  • lack of fire detection system
  • lack of pre-incident planning at facility
  • lack of HAZMAT training
  • lack of situational awareness and risk assessment knowledge
  • no cleaning process was used to clear the conveyor belt before the next load was transferred
  • no immediate evacuation at the first sign of fire occurred
  • no in-place emergency plan addressed response specifically to an incident at the WFC warehouse
  • The WFC did not submit Top-Screen information to DHS as required under CFATS
  • The WFC did not use mitigation systems, such as sprinklers, for its storage of anhydrous ammonia

Recommendations

  1. 2013-02-I-TX R1 | Recipient: U.S. Environmental Protection Agency (EPA) | Status: Closed – Acceptable Alternative Action | Summary: Develop a guidance document on Emergency Planning and Community Right-to-Know Act (EPCRA) requirements that is issued annually to State Emergency Response Commissions (SERCs) and Local Emergency Planning Committees (LEPCs) and ensure that the guidance focuses on which chemicals are exempt and which must be reported, how emergency responders should use Tier I and Tier II inventory reports and Safety Data Sheets, and comprehensive LEPC planning requirements.
  2. 2013-02-I-TX R2 | Recipient: U.S. Environmental Protection Agency (EPA) | Status: Closed – Acceptable Action | Summary: Develop a general guidance document on the agricultural exemption under EPCRA Section 311(e)(5) and its associated regulation, 40 CFR 370.13(c)(3), to clarify that fertilizer facilities that store or blend fertilizer are covered under EPCRA.
  3. 2013-02-I-TX R3 | Recipient: U.S. Environmental Protection Agency (EPA) | Status: Open – Acceptable Response or Alternate Response | Summary: Revise the Risk Management Program rule to include fertilizer grade ammonium nitrate (FGAN) at an appropriate threshold quantity on the List of Regulated Substances and develop guidance for regulated FGAN facilities.
  4. 2013-02-I-TX R4 | Recipient: U.S. Occupational Safety and Health Administration (OSHA) | Status: Closed-Acceptable Action | Summary: Develop and issue a Regional Emphasis Program for Section (i) of the Explosives and Blasting Agent standard, 29 CFR 1910.109(i), in appropriate regions where FGAN facilities similar to the West Fertilizer Company facility are prevalent.
  5. 2013-02-I-TX R5 | Recipient: U.S. Occupational Safety and Health Administration (OSHA) | Status: | Summary: Implement regulatory changes to address FGAN hazards, including either adding FGAN to the OSHA Process Safety Management standard or revising 29 CFR 1910.109 to make clear it applies to bulk FGAN storage and to require noncombustible construction, automatic fire sprinkler systems, fire detection systems, adequate ventilation, isolation from combustible and contaminating materials, and separation distances.
  6. 2013-02-I-TX R6 | Recipient: International Code Council (ICC) | Status: | Summary: Develop a chapter or separate section in a subsequent edition of the International Fire Code for storage and handling of ammonium nitrate that requires automatic fire detection and suppression systems, ventilation, smoke and heat vents, minimum safe separation distances, and prohibition of combustible materials of construction.
  7. 2013-02-I-TX R7 | Recipient: Department of Homeland Security, Federal Emergency Management Agency (FEMA) | Status: Closed – Exceeds Recommended Action | Summary: Create and implement a competitive funding mechanism to provide training to regional, state, and local career and volunteer fire departments on how to respond to fire and explosion incidents at facilities that store FGAN.
  8. 2013-02-I-TX R8 | Recipient: Department of Homeland Security, Federal Emergency Management Agency (FEMA) | Status: Closed – Exceeds Recommended Action | Summary: Ensure that FGAN training includes multiple delivery methods and covers previous FGAN incidents, hazards posed by other materials and chemicals stored near FGAN, pre-incident planning, on-scene emergency response and decision-making, and National Incident Management System and Incident Command System.
  9. 2013-02-I-TX R9 | Recipient: Department of Homeland Security, Federal Emergency Management Agency (FEMA) | Status: Closed – Acceptable Action | Summary: Assist training partners to develop and provide continual oversight for an FGAN training program and evaluate the training curriculum to confirm that it adequately meets course objectives.
  10. 2013-02-I-TX R10 | Recipient: Department of Homeland Security, Federal Emergency Management Agency (FEMA) | Status: Closed – Acceptable Action | Summary: Develop an outreach program that notifies regional, state, and local fire departments about available FGAN training opportunities.
  11. 2013-02-I-TX R11 | Recipient: Texas Commission on Fire Protection (TCFP) | Status: Closed - Reconsidered/Superseded | Summary: Develop minimum standards for course curricula to include hazard awareness of fertilizer grade ammonium nitrate (FGAN) and develop a training program specific to FGAN.
  12. 2013-02-I-TX R12 | Recipient: Texas Commission on Fire Protection (TCFP) | Status: Closed-No Longer Applicable | Summary: Implement outreach to regional, state, and local fire departments that either have FGAN facilities in their jurisdictions or respond as mutual aid to jurisdictions with FGAN facilities, informing them about the new FGAN training certification requirements and opportunities to receive training.
  13. 2013-02-I-TX R13 | Recipient: State Firefighters’ and Fire Marshals’ Association of Texas (SFFMA) | Status: Closed – Reconsidered/Superseded | Summary: Develop a fertilizer grade ammonium nitrate (FGAN) training certification program for fire departments that either have FGAN facilities in their jurisdictions or respond as mutual aid to other jurisdictions with FGAN facilities.
  14. 2013-02-I-TX R14 | Recipient: State Firefighters’ and Fire Marshals’ Association of Texas (SFFMA) | Status: Closed – Acceptable Alternative Action | Summary: Develop an outreach component for the training certification program that notifies regional, state, and local fire departments with FGAN facilities in their jurisdictions about the training certification opportunities available for FGAN.
  15. 2013-02-I-TX R15 | Recipient: Texas A&M Engineering Extension Services (TEEX) | Status: Closed – Acceptable Action | Summary: Develop and administer a hazardous materials training module for career and volunteer fire departments that addresses fertilizer grade ammonium nitrate (FGAN) and other hazardous materials or chemicals that could pose new specialized hazards.
  16. 2013-02-I-TX R16 | Recipient: Texas A&M Engineering Extension Services (TEEX) | Status: Closed – Acceptable Action | Summary: Develop an outreach program that notifies state, regional, and local fire departments about available FGAN training opportunities.
  17. 2013-02-I-TX R17 | Recipient: Texas Department of Insurance (TDI) | Status: Closed – Unacceptable Action/No Response Received | Summary: For companies that provide insurance to agricultural facilities storing bulk fertilizer grade ammonium nitrate (FGAN) in Texas, develop and issue guidance to assist in underwriting risk and conducting annual loss control surveys.
  18. 2013-02-I-TX R18 | Recipient: West Volunteer Fire Department (WVFD) | Status: Closed – Unacceptable Action/No Response Received | Summary: Develop standard operating procedures for pre-incident planning for facilities that store or handle hazardous materials such as fertilizer grade ammonium nitrate (FGAN).
  19. 2013-02-I-TX R19 | Recipient: El Dorado Chemical Company (EDC) | Status: Closed – Acceptable Alternative Action | Summary: For all distributors and bulk retail sites that receive fertilizer grade ammonium nitrate (FGAN) manufactured by EDC, encourage internal monitoring and auditing and establish mutual product stewardship expectations for the downstream chain of customers.

Key Engineering Lessons

  • Combustible construction materials and combustible materials stored near FGAN can intensify a fire and contribute to detonation risk.
  • Indoor FGAN storage areas lacked key safeguards at WFC, including fire detection and automatic sprinkler systems.
  • Contamination of FGAN with soot, molten asphalt, and molten PVC can create a detonable mixture.
  • Ventilation changes during a fire can increase heat release and affect the sensitivity of contaminated FGAN.
  • Pre-incident planning and hazardous materials training for responders are critical for incidents involving FGAN.
  • Fire code, zoning, and separation-distance provisions are important for keeping FGAN storage away from vulnerable occupancies.
  • Loss control surveys and product stewardship programs should specifically address FGAN storage hazards, including combustible construction, nearby combustibles, ventilation, and offsite consequences.

Source Notes

  • Primary source used for incident facts was the final report (source_priority 1); recommendation status summaries were used to update recommendation statuses where available.
  • Direct causes, contributing factors, and organizational/systemic factors were separated using the language and findings in the provided documents.
  • No external facts were added beyond the supplied extracts.

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