[Music] [Sound of sirens] Narrator: At 7:15 p.m.
on February 7th, 2008, a violent explosion erupted at the Imperial Sugar
Refinery in Port Wentworth, GA, just outside Savannah. Narrator:
Surveillance cameras in the area captured the blast, which took the lives of 14 workers
and injured 38 others. The Chemical Safety Board
launched an investigation. The fuel for the blast,
combustible dust. Bresland: Combustible dust can be a
catastrophic hazard in American industry. Three of the four most serious accidents that we
have investigated have been combustible dust explosions. [Sound of sirens] Narrator: In 2006, this pattern of accidents spurred the
CSB to issue a comprehensive study of combustible dust, which uncovered 281 fires and explosions
that had occurred over the previous 25 years. The study revealed what the CSB called
"a significant industrial safety problem". Combustible dust fires and explosions
continue to occur frequently, fueled by accumulations of combustible dust, which can
gather over years in hidden places or in plain sight. Bresland: No company wants to see its facility
blown up and destroyed and its employees killed, but they just don't understand
what the hazard is. They don't realize that they have a hazard here
until that one day when the explosion occurs and it's a terrible tragedy for them and
they look back and say, if we'd only known. [Music] Narrator: When Tammy Miser got a
phone call late one evening in 2003, she worried it would be about her brother, Shawn Boone,
who worked at an automotive parts factory. Miser: And we usually
didn't answer the phone that way, but we knew when it kept ringing
that there was something wrong, so we answered it and there had been
an accident there before, so I knew. I knew they were calling me;
it was my brother. Narrator: Shawn Boone was a mechanic at the
Hayes Lemmerz Plant in Huntington, Indiana. The company produced
aluminum car wheels. The process of finishing the
wheels left behind aluminum scraps, which were chopped into small pieces and
sent to a furnace to be melted and reused. Chopping, drying and blowing the
dried chips through the transfer piping created highly combustible aluminum dust, which flowed through ducting to a steel drop box
outside the building where large particles were trapped. The air then entered a dust collector,
which removed finer aluminum particles. Over time aluminum dust
accumulated inside ducts. In addition, there were leaks in the piping
used to transfer aluminum chips, which caused dust to build up on
surfaces throughout the furnace area. Aluminum dust landed on
beams, ledges and equipment. In some places the dust
was several inches deep. On the night of October 29th, about ten minutes
after workers started the aluminum chip melting process, aluminum dust inside the dust collector
was suddenly ignited, perhaps by a metal ember or impact spark
resulting in a large explosion. The blast propagated back through the duct
into the steel drop box, blowing it apart. The fireball and pressure wave
continued back through the duct system, into the building gaining intensity as
the accumulated aluminum dust ignited. [Sound of explosions] Narrator: The violent disturbance shook loose
dust that had built up on external surfaces. At about 8:30 p.m., plant mechanic Shawn Boone
was one of several workers in the area of the furnace. Without warning, a fireball erupted from the furnace, engulfing the area and igniting
airborne dust in a second larger explosion. [Sound of explosion] Narrator: The explosion blew a 50-foot
wide hole through the roof of the building. Coworkers found Shawn Boone lying on the
floor near the furnace, gravely injured. He was rushed to the hospital
and put on life support. Miser: And they told us that
his internal organs were burnt and they could take his arms
and they could take his legs, but he probably wouldn't make it and it would
just prolong it, so we went ahead and took him off. Narrator: Shawn Boone was one of 14
dust explosion fatalities in 2003 alone. Launching a comprehensive investigation into
the hazard, the CSB held two public meetings, convening panels of experts and
listening to extensive public comment. Sallman: First, combustible dust is a real
serious problem in all of general industry. Narrator: The CSB report concluded
that good engineering and safety practices to prevent dust explosions
have existed for decades, but there is no comprehensive federal
standard requiring adherence to those practices and many companies are not taking
effective actions to control dust hazards. As a result, the Board recommended
increased regulation of dust hazards. The final report was approved at a public
meeting in Washington in November, 2006. Merrill: ... carried and the
report and recommendations are adopted. Bresland: We found in our study that
the issue of combustible dust explosions is not focused on one
particular industry. It happens right across all
industries and industries that, where you perhaps you wouldn't
expect there to be an explosion. Narrator: Industries at risk include food
production, metal processing, wood products, chemical manufacturing, rubber and
plastics and coal-fired power plants. The CSB study provides many examples of
the continuing toll from dust explosions. Coal dust exploded in 1999 at the
Ford River Rouge Plant near Dearborn, Michigan. Six workers died
and 36 were injured. Resin dust exploded at the Jahn Foundry
in Springfield, Massachusetts in 1999, killing three workers
and injuring nine others. Rubber dust exploded at Rouse Polymerics in
Vicksburg, Mississippi in 2002, leaving five dead. A nylon fiber explosion destroyed
Malden Mills in Methuen, Massachusetts in 1995. In fact, between 1980 and 2005, the CSB found at
least 281 combustible dust fires and explosions that caused 119 deaths, 718 injuries
and major damage to industrial facilities. Spencer: NFPA supports ... Narrator: Amy Beasley-Spencer is a combustible dust
expert at the National Fire Protection Association or NFPA. Beasley-Spencer: Beyond the
loss of life and the injuries, when you think about the
economic impact of a dust explosion, you hear about plants
being completely destroyed. There's loss of jobs; it's an
economic impact on the entire community. Narrator: The CSB report called on OSHA to
establish a comprehensive regulatory standard designed to prevent dust
explosions in general industry. The Board said OSHA should base the new
regulation on the current standards of the NFPA. These Codes address hazard assessment,
engineering controls, housekeeping, building design, explosion protection,
operating procedures and worker training. Beasley-Spencer: The NFPA Codes and Standards
have been in existence since the early 1920s and there are seven Codes and Standards
that deal directly with dust. It's a tragedy to have
even one loss of life, because the technology is out there
to prevent these dust explosions. Narrator: In addition to the NFPA,
the Center for Chemical Process Safety, as well as a leading insurance company have developed
recommended practices on controlling combustible dust. The Board also called for improved training
of OSHA inspectors to recognize dust hazards, Interim CSB Executive William Wright
explained the recommendation before the House Committee on
Education and Labor in March, 2008, citing three dust explosions
the CSB had investigated in 2003. Wright: State OSHA officers had inspected
all three facilities prior to the accidents, but the dust hazards were
never recognized or cited. Furthermore, the CSB determined that all
three explosions could likely have been prevented if the facilities had implemented
NFPA recommended practices. Narrator: In addition, the Board recommended
that OSHA revise its Hazard Communication Standard, to ensure that material safety datasheets
better communicate dust hazards to workers. In response to the CSB's recommendations, in 2007,
OSHA increased the enforcement of existing regulations through a new national
emphasis program on combustible dust. Bresland: Without a
comprehensive standard for combustible dust, it's difficult for businesses to
know which specific NFPA provisions or other requirements
they may be subjected to. Narrator: The explosions tragically continue. The list includes the blast that
crippled the Imperial Sugar Refinery outside Savannah, Georgia
in February, 2008. Wright: Since 2005, about 70
additional dust explosions have been reported. And in fact,
the Imperial accident last month is the deadliest industrial dust
explosion in the United States since 1980. Narrator: CSB Chairman, John Bresland. Bresland: I toured the facility
about six weeks after the explosion. The damage that was done
there was catastrophic. As you walk around the facility, you think
of the people who were working there that day, who were killed
and severely injured. It was a difficult experience
to walk around that facility. It was a very sobering experience. Blair: What is so frustrating about dust explosions
is that they are so preventable. And I believe that one of the
reasons that dust explosions continue to occur may simply be a lack
of understanding about the materials. Most solid organic materials will
explode if the particles are small enough and they're dispersed in a
sufficient concentration. Some of the materials that could form combustible dust
and there are lots of them, could include coal, sawdust, food products like sugar and flour,
pharmaceuticals, many chemicals and even many metals. Narrator: Like all fires, a dust fire
requires fuel, oxygen and an ignition source. A dust explosion requires two
additional elements; dispersion and confinement. [Sound of explosion] Narrator: The CSB
commissioned laboratory tests, using a sample of fine polyethylene dust found by
investigators in the rubble of a North Carolina factory. Dust is dispersed into a flame,
creating a fireball. When the dust is confined within a
structure or a piece of equipment, a powerful explosion
can occur and propagate. As this coal industry video demonstrates. Dust may accumulate on surfaces
and lie undisturbed for years. Then some initial fire or explosion, known as a
primary event, shakes it loose and ignites it. Beasley-Spencer: It causes a
pressure wave to go through the plant and that dislodges all of the dust that is
perhaps unknown, up on the rafters, on the beams, on the tops of equipment and that serves as the fuel
for the secondary explosions that move through the plant. Blair: Most of the fatalities and the devastating
injuries have been caused by these secondary dust explosions. Narrator: According to the NFPA,
a catastrophic explosion can occur from as little as
one-thirty-second of an inch of accumulated dust; around the thickness of a dime, covering
just five percent of a room's surface area. The NFPA therefore recommends that
company's control fugitive dust emissions, design facilities to prevent dust from migrating
and accumulating and perform rigorous housekeeping to remove any dust
that does build up. Bresland: The NFPA Codes have been
adopted either at the State level or in some cases at the local level,
at the city level. But the problem is, they're
not enforced in any regular way. Narrator: A catastrophic dust explosion at the West
Pharmaceutical Plant in Kinston, North Carolina in 2003 reveals what can happen when companies do not
properly assess the hazards from combustible powders and do not design their
buildings and equipment appropriately. West Pharmaceutical made small rubber medical
products, such as syringe plungers and stoppers, at a large manufacturing
facility with nearly 300 workers. In the process, large batches of rubber
were compounded and rolled into long strips. To keep these strips from sticking together, they
were dipped in a vat containing a whitish slurry of water and finely powdered polyethylene,
a petroleum-based wax-like plastic. The coated rubber strips were then blown
dry with fans and folded for later processing. As the rubber sheets dried,
combustible polyethylene dust, which was not visible to workers, but is colored
white here for illustration, was blown into the air. Over the years, the air
conditioning system drew polyethylene dust into the hidden space above an acoustic tile ceiling
that was suspended over the production area. There the dust gradually built up to a thickness
of up to one-half inch on ceiling tiles, beams, conduits and light fixtures, just a few
feet over the heads of unsuspecting workers. January 29th began as a
routine workday at the West Plant. But at about 1:28 p.m., a small fire or explosion occurred somewhere near the production area. [Sound of explosion] Narrator: It lofted the accumulated
dust above the ceiling into a thick cloud, which then ignited in a much
more violent secondary explosion. Some employees described a sound like rolling thunder,
as the dust explosion spread throughout the
space above the ceiling ... snd ripped through the building. The accident at West Pharmaceutical
Services took the lives of six employees and injured 38 others,
including two firefighters. Selk: The thing that set up the tragedy at West was
the mere accumulation of hazardous dust above a ceiling. Beasley-Spencer: The NFPA Code says that any
openings where a dust could accumulate must be sealed. The solution would have been to either
seal it or to not have a suspended ceiling. Narrator: Another cause of the West accident was that workers were not informed of the dust
explosion hazard arising from the polyethylene slurry, a fact that should have been
included on the material safety datasheet. Beasley-Spencer: At West Pharmaceutical,
the dust wasn't well recognized as a hazard, because it was actually in a slurry form,
so the actual processing of the slurry, the drying of it, created the dust and the
dust migrated above the suspended ceiling. Narrator: Cleaning above the ceiling was overlooked
in West's otherwise rigorous housekeeping program. Selk: Cleanliness was a
matter of pride for the West staff. Being in the pharmaceutical services industry,
they kept the production area very, very clean. Some of them knew that large amounts of dust
had accumulated above the suspended ceiling. Had they been aware that
that was an explosive material, they could have informed
management of the accumulation and perhaps the situation could have
been rectified before the explosion. Narrator: Jim Dahn is a
leading expert on combustible dust. Dahn: If you've got a dust, you need to know
what the ability of that dust is to explode and to be able to characterize that dust
in terms of does it take a little energy? Does it take a lot of
energy to ignite it? Will this dust, when it explodes,
create a very major overpressure? Those are the things
that need to be onto a MSDS. Narrator: The CSB found that the
problem of inadequate MSDSs is widespread. Of 140 MSDSs for combustible powders, the CSB found
that very few included adequate dust explosion warnings or referred readers to the
appropriate NFPA Standards. Bresland: There needs to be better
communication to workers on the issue of combustible dusts and that should be done through improved
information on Material Safety Data Sheets. Narrator: Less than a month after
the West Pharmaceutical accident, a fatal dust explosion crippled the
CTA Acoustics Plant in Corbin, Kentucky. The disaster at CTA,
which claimed seven lives, illustrates the critical importance of following
NFPA recommended practices to control dust hazards. The CTA facility, with more than 500 personnel,
produced fiberglas acoustic insulation for automobiles. Covering 300,000 square feet,
it have five production lines. At Line 405, fiberglas was fed along a
conveyor system and spread to create a web. Black phenolic resin powder
was deposited onto the fiberglas. Hundreds of thousands of pounds of the combustible
resin powder were used in the plant every month. Next, the mat former used air suction to
spread the resin through the fiberglas. Excess powder and fibers were drawn up into a dust
collector and rapidly accumulated on long cloth bags. After the mat former, a nylon facing was rolled onto
the fiberglas, before it entered a gas-heated curing oven. Combustible resin accumulated in the oven, resulting in
frequent small fires that were extinguished by workers. During each shift, the line
was shut down for cleaning. On the roof, employees routinely used compressed air
to dislodge dust that had built up in the ductwork, dumping the material into a large
open box on the production floor. On the production line, workers also used
compressed air to blow dust off equipment. They swept the
production floor with brooms. These cleaning activities
created dust clouds so dense that large fans were used to blow
the dust away from the operators. This increased the
dispersion of dust in the plant. The dust settled on horizontal surfaces
throughout the entire production area. Over years of operation,
dust built up on top of pipes, electrical conduits and other
hard-to-clean elevated surfaces, such as roof trusses. A pile of resin dust more than a foot deep
had built up on top of the blend room, due to periodic
cleaning of clogged equipment. On the morning of February 20th, 2003,
Production Line 405 was shut down for routine cleaning. The oven was still on, with one of its
doors left open to control the temperature, because the oven thermostat
had broken weeks earlier. CSB investigators later determined that
most likely a small fire, unseen by workers, had started inside the oven, fueled
by a buildup of combustible resin. During cleaning, workers had
discovered that a transition duct, leading from the mat former to
the dust collector, was clogged. They used a compressed air lance to dislodge the material
back through cleanout doors, into the production area. Together with other cleaning activities,
this created a dense dust cloud around Line 405. A wall fan blew the cloud
toward the open oven. The dust was ignited by
the small fire inside. [sound of explosion] Flames erupted from the oven, igniting
the larger dust cloud, which exploded. [Sound of explosion] Narrator: This was quickly followed by a
second dust explosion ... [Sound of explosion] Narrator: ... at the other
end of the production line. Four employees nearby were injured;
one later died from severe burns. The force of the two explosions shook the building and
dispersed accumulated dust throughout the production area. This airborne dust fueled a quickly moving fireball,
spreading west along the roof trusses, toward Production Line 403,
which was also surrounded by dust. [Sound of explosion] Narrator: Four workers in
this area were fatally burned. The fireball continued past Line 402,
fatally injuring two more workers and then to Line 401, where a third explosion occurred ... nearly 300 feet from
where the first blast was ignited. Three workers in this area
were severely burned. Hoyle: The four production lines
were not adequately segregated and this allowed the dust explosion to very quickly
travel from one production line to the next to the next. Hoyle: And in this case, most of the employees who died were actually
working a far distance from where the initial fire began. Narrator: NFPA recommends minimizing
horizontal surfaces where dust can collect. Bu the CSB found that
this was not done at CTA. Beasley-Spencer: At CTA Acoustics, there were many actions that were being completed
that were prohibited in the NFPA Codes and Standards. For instance, if you're using compressed air, that can create more dust in the air to cause
a larger fuel load for the actual explosion. Narrator: CTA personnel also used brooms
and fans to clean the production lines, which dispersed dust
throughout the building. NFPA Standards emphasize the use of safe cleaning
methods, such as vacuuming with specialized equipment. Hoyle: When normal, routine daily housekeeping, workers address the working and
walking surfaces in their production areas. They address their equipment;
the places that they can see. But when it comes to preventing dust explosions,
much more is needed. You have to clean in the out-of-the-way places,
up near the rafters. Beasley-Spencer: You also don't
want to over-rely on housekeeping, because if you have housekeeping around the clock
and you're still seeing layers of dust, you might want to look at your system to see why
that dust is being produced in the first place. Narrator: The CSB also found the Material Safety
Data Sheets for the phenolic resin powder used at CTA did not adequately warn of
the dust explosion hazard. Kentucky State Fire Inspectors had not
visited the facility since its construction in 1972. Insurance companies had inspected
the plant on multiple occasions, but never identified the dust hazard;
neither had State authorities. Hoyle: We found that Kentucky OSHA had in fact
inspected this facility not long before the explosion, yet they had not uncovered
the combustible dust hazard. We further learned that they had not received
specific training to be able to detect this deadly hazard. Narrator: Following the CSB investigation, Kentucky officials established a new program
to inspect facilities with dust hazards and developed an educational bulletin on dust,
which was distributed to thousands of facilities. [Music] Off Screen Voice: There's been
a big explosion at the company! Beasley-Spencer: Why do these accidents
keep occurring is the age-old question. The knowledge is out there to make sure
that no deaths occur due to dust explosions. Selk: I think the big problem with combustible dust
is that we underestimate its hazards. We become complacent and we fail
to take the necessary precautions. Dahn: But it's not going to happen in my plant,
because it's never happened that way before. I mean, we've been operating for
40 years and never had a problem. That kind of a logic is one that
can guarantee you'll get into trouble. Any material that they have in
their process, in a dust form, should be tested to determine if it
is a dust explosion potential or not. [Sound of explosion] Narrator: In the 1970s and '80s, the U.S. experienced a series of grain
dust explosions that killed many people. OSHA responded with new regulations in 1987,
requiring preventive maintenance, worker training and formal dust
cleaning programs in grain-handling facilities. A 2003 OSHA analysis concluded that the number of
deaths from grain dust explosions had dropped dramatically. Bresland: OSHA has a specific standard for grain dust
and that's been a very successful standard and it has significantly reduced the
number of accidents involving grain dust. Beasley-Spencer: I believe if there were a
national OSHA requirement dealing with dust explosions, that the incidents would
be significantly decreased. Narrator: In April, 2009, Secretary of Labor Hilda Solis
announced plans for a comprehensive regulatory Standard. Solis: Where workers are in danger, where mandatory
regulations make sense, we will act and we will implement. And I'm announcing today that OSHA will
begin the rulemaking on combustible dust. Bresland: What I feel that we need to do to
prevent combustible dust explosions is threefold. We need education, we need industry
to understand what the hazards are. We need regulation. We need a comprehensive
combustible dust regulation. And we need
enforcement of the regulation. And I feel if we do all three, we'll go a
long way to preventing these terrible tragedies that we're seeing with
combustible dust explosions. Miser: The only way that, you know, to keep my
brother from dying in vain, would be to make changes. And if there's not a change made, well,
then you know it's going to happen again. Bresland: I hope that people who
watch this video will take the lesson that they really need to do something
to prevent combustible dust explosions. Narrator: For more information on
combustible dust, please visit CSB.gov. [Music]