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West Pharmaceutical Services Dust Explosion and Fire

Overview

On January 29, 2003, an explosion and fire destroyed the West Pharmaceutical Services plant in Kinston, North Carolina. The fuel for the explosion was a fine plastic powder that accumulated above a suspended ceiling over a manufacturing area and ignited. The incident killed six employees, injured dozens of others, and caused major facility damage and job losses.

Incident Snapshot

Field Value
Facility / Company West Pharmaceutical Services, Inc.
Location Kinston, NC
Incident Date 01/29/2003
Investigation Status The Board voted 4-0 to approve the final report on this investigation at a public meeting in Kinston on September 23, 2004.
Accident Type Combustible Dust Explosion and Fire
Final Report Release Date 09/23/2004

What Happened

  • On January 29, 2003, at 1:28 pm, an explosion and fire occurred at the West Pharmaceutical Services, Inc., plant in Kinston, North Carolina.
  • The explosion occurred abruptly during a routine workday and was heard by employees throughout the plant and by people outside the facility.
  • The explosion broke feeder lines to the fire sprinkler system, disabling it.
  • A large fire developed, particularly in the raw material warehouse, and burned for two days.
  • The explosion and ensuing fire heavily damaged the compounding section of the Kinston facility and rendered most of the building unusable.
  • West later relocated to an available industrial facility several miles south of the destroyed plant.

Facility and Process Context

  • The Kinston facility manufactured rubber drug-delivery components such as syringe plungers, septums, and vial seals.
  • Production operations included rubber compounding, molding, and extrusion.
  • The rubber compounding process consisted of two separate production lines, each with a mixer, a mill, and batchoff equipment.
  • At the plant, batches of rubber were compounded in mixers, rolled into strips, and then either molded or shipped off site.
  • To reduce the stickiness of the rubber, the strips were conveyed through a tank containing very fine talc-like polyethylene powder mixed with water and then blown dry with fans.
  • The compounding area had a suspended or drop ceiling above the production area, and dust accumulated in the space above it.
  • The HVAC or comfort air system created a slight negative pressure above the suspended ceiling, drawing room air into that zone where dust could settle.
  • The area above the ceiling contained beams, conduits, duct work, light fixtures, and other surfaces where dust accumulated.
  • The plant used outside engineering contractors for design and implementation of the process.

Consequences

  • Fatalities: 6
  • Injuries: 38, including two firefighters; a student at a school more than half a mile away was injured by shattered glass
  • Environmental release: Flaming debris set woods on fire as far as two miles away; EPA and the North Carolina Department of Environment and Natural Resources performed air monitoring and screening of water runoff from the firefighting effort.
  • Facility damage: The rubber-manufacturing area of the plant was destroyed, the warehouse collapsed, and most of the building was rendered unusable. The compounding section was heavily damaged, exterior sheathing was destroyed, masonry block walls were knocked down, and the building was rendered mostly unusable.
  • Operational impact: West relocated to an available industrial facility several miles south of the destroyed plant and did not resume rubber compounding at the new facility, resulting in job losses in Kinston.

Key Findings

Immediate Causes

  • Accumulated polyethylene dust above the ceiling tiles fueled the explosion.
  • The first explosion dispersed other dust accumulations into the air around the production area and ignited them, causing a cascade of fires and explosions.
  • The investigation could not conclusively determine what dispersed the dust or what ignited it.

Contributing Factors

  • Dust was drawn upward through ventilation air intakes located over the acoustic tile ceiling.
  • Above the ceiling, dust gradually built up on ceiling tiles, beams, conduits, and light fixtures.
  • As much as a ton of combustible powder could have accumulated in the area above the ceiling.
  • The process was not suitable for handling combustible powders such as polyethylene or zinc stearate.
  • The use of fans to dry the coated rubber dispersed dust throughout the work area.
  • The unsealed acoustic tile ceiling allowed large amounts of dust to accumulate in concealed areas that were difficult to clean.
  • The electrical fixtures and wiring in the production area were general-purpose and not rated for use around combustible dust.
  • The batchoff machine was a source of fugitive emissions of combustible dust.
  • There was no organized cleaning program for surfaces above the ceiling.
  • West changed out ceiling tiles from time to time for aesthetic reasons, but the frequency was insufficient to address dust accumulation.
  • The comfort air system drew a portion of its air from above the ceiling and returned it to the room below.
  • The mineral oil tanks released their combustible contents following the initial explosion and fire, adding fuel to the fire.
  • The explosion broke feeder lines to the fire sprinkler system, disabling it.
  • The MSDS warned of the polyethylene powder’s potential to cause a dust explosion, but the Crystal MSDS for the paste did not warn of the hazard of a dust explosion from dried paste.
  • Employees had not received any significant training about combustible dust hazards.
  • The Kinston facility was not required to comply with NFPA 654 under either North Carolina state law or federal workplace safety regulations.
  • North Carolina workplace and fire safety inspectors had only limited knowledge of combustible dust hazards.

Organizational and Systemic Factors

  • West did not reexamine the safety of the powder or consult the NFPA standard when it began using polyethylene in the manufacturing process at the Kinston facility in 1996.
  • West did not perform adequate engineering assessment of the use of powdered zinc stearate and polyethylene as antitack agents in the rubber batchoff process.
  • West engineering management systems did not ensure that relevant industrial fire safety standards were consulted.
  • West management systems for reviewing material safety data sheets did not identify combustible dust hazards.
  • The Kinston plant’s hazard communication program did not identify combustible dust hazards or make the workforce aware of such.
  • West did not conduct a formal project safety review of the ACS process at the time of design.
  • West’s new material review process did not identify the combustible dust hazard in the 1990 review of Acumist or the later review of a slurry containing Acumist.
  • West corporate engineering department focused on product development and relied on several engineering contractors for design, planning, and implementation.
  • West corporate chemists developed the formulations for the rubber and specified the powders to be used in antitack solutions.
  • West’s training had not informed workers of combustible dust hazards.
  • Several safety inspectors visited the facility but did not recognize or identify the hazard.
  • Crystal, Inc.–PMC did not include combustible dust warnings in its Material Safety Data Sheet for the polyethylene paste.

Failed Safeguards or Barrier Breakdowns

  • The building’s sprinkler system was disabled.
  • There was no organized cleaning program for surfaces above the ceiling.
  • The unsealed acoustic tile ceiling allowed dust to accumulate in concealed areas.
  • The electrical fixtures and wiring in the production area were general-purpose and not rated for use around combustible dust.
  • Penetrations of partitions, floors, walls, and ceilings were not sealed dust-tight.
  • Spaces inaccessible to housekeeping were not sealed to prevent dust accumulation.
  • Material Safety Data Sheets did not adequately identify combustible dust hazards.
  • The hazard communication program did not make the workforce aware of combustible dust hazards.
  • West did not reexamine the safety of the powder or consult the NFPA standard when it began using polyethylene in the manufacturing process.
  • West did not conduct a documented investigation of the earlier welding-related fire incident.
  • The batch-off machine’s air fans discharged air into the room, carrying dust into the facility.
  • The sprinkler system was rendered inoperable from the outset because the explosion broke feeder lines to the system.

Recommendations

  1. 2003-07-I-NC-R1 — Recipient: West Pharmaceutical Services, Inc. — Status: Open — Revise policies and procedures for new material safety reviews. Use the most recent versions of MSDSs and other technical hazard information, fully identify hazardous characteristics of new materials, and include an engineering element that identifies and addresses the potential safety implications of new materials on manufacturing processes.
  2. 2003-07-I-NC-R2 — Recipient: West Pharmaceutical Services, Inc. — Status: Open — Develop and implement policies and procedures for safety reviews of engineering projects. Address hazards of individual materials and equipment and their effect on entire processes and facilities, consider hazards during conceptual design as well as engineering and construction phases, cover work performed by outside firms, and identify applicable codes and standards in the design.
  3. 2003-07-I-NC-R3 — Recipient: West Pharmaceutical Services, Inc. — Status: Open — Identify West manufacturing facilities that use combustible dusts and ensure that they incorporate applicable safety precautions described in NFPA 654. Ensure that penetrations of partitions, floors, walls, and ceilings are sealed dust-tight and that spaces inaccessible to housekeeping are sealed to prevent dust accumulation.
  4. 2003-07-I-NC-R4 — Recipient: West Pharmaceutical Services, Inc. — Status: Open — Improve hazard communication programs so that the hazards of combustible dust are clearly identified and communicated to the workforce. Ensure that the most current MSDSs are in use and that employees receive training on the revised or updated information.
  5. 2003-07-I-NC-R5 — Recipient: West Pharmaceutical Services, Inc. — Status: Open — Communicate the findings and recommendations of this report to the West Pharmaceutical Services workforce.
  6. 2003-07-I-NC-R6 — Recipient: North Carolina Department of Labor — Status: Open — Identify the manufacturing industries at risk for combustible dust explosions and develop and conduct an outreach program on combustible dust hazards.
  7. 2003-07-I-NC-R7 — Recipient: North Carolina Building Code Council — Status: Open — Amend Chapter 13, Section 1304, of the International Fire Code as adopted by the North Carolina Fire Code to make compliance with NFPA 654 mandatory.
  8. 2003-07-I-NC-R8 — Recipient: North Carolina Code Officials Qualification Board — Status: Open — Incorporate the provisions of NFPA 654 into the training program for state and local building and fire code officials.
  9. 2003-07-I-NC-R9 — Recipient: Crystal, Inc.–PMC — Status: Open — Modify the material safety data sheet for manufactured polyethylene antitack agents to include hazards posed by the end use of the product.

Key Engineering Lessons

  • Combustible dust can accumulate in concealed spaces above suspended ceilings and remain out of sight until an explosion occurs.
  • Ventilation and air-handling arrangements can draw dust into hidden spaces and promote accumulation above ceilings.
  • Unsealed ceilings, unsealed penetrations, and spaces inaccessible to housekeeping can create conditions for hazardous dust buildup.
  • General-purpose electrical equipment in areas where combustible dust may be present is not an adequate safeguard.
  • Dust control and housekeeping must address hidden surfaces above ceilings, not only visible process areas.
  • Material and process reviews must consider the end-use hazard of antitack agents and other powders in the actual manufacturing process.
  • Engineering reviews should include applicable fire and dust explosion standards such as NFPA 654 when combustible powders are introduced into a process.

Source Notes

  • Priority 1 final report information was used to resolve conflicts where it differed from supporting documents.
  • The final report states that the investigation could not conclusively determine the ignition source or the exact mechanism that dispersed the dust.
  • Some supporting documents use slightly different terminology for the same materials, such as polyethylene powder, polyethylene dust, Acumist, and slab dip; these were preserved where explicitly stated.
  • Recommendation recipients and wording were normalized to the most authoritative available source while preserving official terminology where possible.

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