Fire

The documented incidents that occurred at the Hoeganaes Corporation Gallatin plant in 2011 illustrate three main points of failure by the employer and/or Management. The first point of failure is gross negligence, by Hoeganaes Corporation Management, to implement corrective actions for reported hazards ascertained by the insurance audit findings conducted in 2008.

Furthermore, Hoeganaes management should have conducted a combustible dust test after the 1996 employee fatality from metal dust ignition resulting in smoke inhalation. (Brauer, 2016) Further assessment reveals that prior to these incidents, no evidence that any company or third-party safety engineer had been tasked to suggest or advise appropriate engineering controls that could have reduced the risk of explosions and flash fire of the powdered metals. Had the facility conducted regular job safety analysis (JSA) or job hazard analysis (JHA) with associated risk assessments, identified hazards leading to corrective measures could have been implemented that would have greatly reduced if not altogether eliminated the incidents that occurred in 2011.

The second point of failure is a clear lack of understanding and education on the combustibility and operational hazards associated with powdered metals (PM) specifically iron dust as determined by the NFPA 499. This includes the specific regulatory knowledge on flash and ignition points of iron dust, electrical hazards with operational infrastructure processes, and federal standards on locations for electrical installations in chemical process areas that contain Class I materials listed in the NFPA 497 such as hydrogen.

The third point of failure is a companywide lack of near-miss reporting that informs and potentially elicits necessary safety changes in the workplace. Chemical Safety Board (CSB) investigations found that periodic small dust fires ignited in certain areas of the Gallatin plant where some employees told the state inspectors they put out fires once or twice a month; others said the fires came about once a week. Because the fires did such little damage, the workers had come to accept it as the norm and didn’t feel the need to report the incidents. (“Combustible dust explosion and fire case studies”, 2014) Most safety implementation programs are reactive, not proactive, and some companies wait for fatalities, major losses, or serious incidents to occur before taking the necessary steps to prevent a recurrence. Near-miss incidents often come before loss-producing situations or incidents but are often ignored or overlooked as there was no injury, damage, or loss of life. In the Hoeganaes Corp. Gallatin plan, there was no reporting culture where employees were encouraged to report the aforementioned close calls or near misses. Thus, many opportunities to prevent the incidents were lost. Historic evidence has proven repeatedly that most incident losses, both serious and catastrophic, were preceded by warnings or near-miss incidents. When workers recognize and report near-miss incidents worker safety can significantly improve as well as enhance a company’s safety culture. (“Implementing a near-miss reporting system”, 2015)

In order to correctly review all of the failures leading up to the incidents that occurred at the Gallatin, TN plant in 2011 a thorough risk assessment must be performed. The assessment will aid in developing any mitigation methods and/or corrective actions that the employer needs to take in order to prevent a recurrence of similar events. A detailed assessment expanding on the above three main points of failure will cover the unique factors associated with each point focusing on the components and choices which led to this catastrophic failure of safe work practices and loss of life.

The first risk assessment would be to review the identified hazards and existing safety controls, if any, of the Gallatin, TN Facility where operations occurred. Utilizing the 5×5 risk assessment matrix, found in Figure I, compares outcomes to likelihoods aids in answering each identified hazard to determine severity by rating the hazards, processes, and equipment that led to the reported incidents that took place at the Gallatin plan. The matrix that was used is in Figure 1.

Figure 1

Risk assessment evaluation of identified fire hazards at the Gallatin, TX plan facility shall include, at a minimum: A combustibility test for the iron dust; PM product transfer devices (bucket elevators and conveyors) and their associated electrical hazards; Electrical safety engineering controls and subsequent employee training; Preventative Maintenance processes for combustible gas lines and employee training; facility building layout with accumulated iron dust deposits as well as fugitive dust releases, placement of service equipment and cooling devices near major gas lines, including preventative maintenance schedules/reporting; forklift/crane safe operations and associated training; lockout/tagout procedures; fire suppression systems (if any); Emergency action plans for fire emergencies and associated training frequencies; dust collection devices and preventative maintenance schedules; and finally hazard identification reporting and pre-job safety meeting processes.

In order to correctly assess the risk, an analysis of the combustibility test performed by the CSB is referenced to determine likelihood and severity ratings from the matrix. The CSB test analysis data indicated that the iron powder is in fact combustible and is covered by the requirements of the NFPA 484 (Section 4.4.1). (Brauer, 2016) The values garnered from this investigation indicate that the dust collected for these test procedures, produces a weak explosion relative to other specks of dust of similar combustibility factors, however, due to this indicative fact it is still considered combustible by the OSHA definition and can result in a flash fire cable of causing injuries and fatalities. (Brauer, 2016) Taking into consideration of these investigation findings the likelihood of an injury occurring during operations is likely to very likely equaling a level of risk of 20 to 25, which is reflective of the events that occurred at the Gallatin Plant in 2011. The severity rating for operational injury probability is rated at 5, which indicates an unaccepted rating for operational usage in the workplace and that some degree of control needs to be implemented in order to reduce this rating.

The major variables that led to the incidents at this facility were lack of management oversight and consideration for worker safety, failure to meet any regulatory standard, lack of training and/or education on work hazards associated with PM, lack of hazard reporting for common flash fires, unclear jurisdiction for external audit enforcement for corrective actions, and failure to regulate any sort of preventative maintenance that would remove accumulated iron dust around the facility, exposed wiring, engineering controls which reduce occurrences of fire emergencies.

Preventive maintenance consists of the care and servicing of organizational assets to maintain them in optimal operational conditions through systematic inspections and observations in order to detect and correct issues before a breakdown occurs. (Ralitsa_Peycheva, 2019)

Adopting a preventative maintenance program is needed when the quality of production gets affected due to unreliable equipment, the repair cost is too high, or when an incident occurs from faulty equipment. The purpose of a successful preventative maintenance program is to finally extend the life of equipment and tools by predicting failures. The implementation of the process guarantees the plant’s reliable and efficient performance by ensuring that equipment does not break down when you need it most. At the Gallatin Plan, it was reported that the bucket elevators had a tendency to go “Off-track” when the belt pulling the buckets became misaligned. Additionally, the CSB found instances through employees that the dust bag collection system was frequently out of order and not working properly allowing for fugitive dust to accumulate throughout the plant. In another part of the CSB investigation, it was found that exposed electrical wiring on the elevator, which should have been safely covered. Further preventative maintenance procedures were needed in the band furnace igniters that frequently need replacing, in addition to furnace cooling mechanisms and where the runoff drains to. (Brauer, 2016) Machinery wears over time but it is essential to understand that preventive replacement prior to failure is far more cost-efficient than waiting for the potential consequences of a failure in service.

Each of these findings relating to preventative maintenance considers poor housekeeping the likelihood of an injury occurring during operations is likely to very likely equaling a level of risk of 20 to 25, which is reflective of the events that occurred at the Gallatin Plant in 2011. The severity rating for operational injury probability is rated at 5, which indicates an unaccepted rating for operational usage in the workplace and that some degree of control needs to be implemented in order to reduce this rating.

Again the variables that needed to be overcome that led to the incidents at this facility center around lack of management oversight and consideration for worker safety, failure to meet any regulatory standard, lack of training and/or education on work hazards associated with PM, lack of hazard reporting for common flash fires, unclear jurisdiction for external audit enforcement for corrective actions, and failure to regulate any sort of preventative maintenance that would remove accumulated iron dust around the facility, exposed wiring, engineering controls which reduce occurrences of fire emergencies. Additionally, there is no reporting of regular internal safety audits, near-miss reporting, site operational risk assessments, lockout/tagout procedures, or any indication of fire suppression systems other than portable fire extinguishers.

The building construction section of the National Fire Protection Association (NFPA) codes states, “Avoid beams, ledges or other places where dust may settle, particularly overhead.” The Gallatin plant, which was built in the 1980s was not designed to avoid the significant overhead accumulation of dust. (Brauer, 2016) This NFPA code calls for designing and maintaining dust-tight equipment to avoid leaks and, if not possible, enforce good housekeeping practices to avoid accumulation. Additionally, the NFPA code recommends caution around sources of ignition where combustible dust may accumulate, such as bucket elevators, forklifts, gas lines, and the igniters for furnaces. The NFPA suggests relocating dust collectors outdoors or in separate rooms equipped with explosion venting. (Brauer, 2016) The Gallatin plant during the 2011 incidents had neither of these controls in place.

The CSB investigation revealed that significant quantities of iron dust had escaped from the equipment throughout the Gallatin plant including the enclosures on the conveyance equipment. Additionally, the dust collection systems were known to be unreliable and did not prevent large amounts of combustible iron dust from becoming airborne throughout the facility resulting in multiple surface accumulations throughout the processing areas. (Brauer, 2016)

Further investigation into the hydrogen explosion resulted in findings that the hot water from cooling the furnaces was draining onto the various gas line pipes locked in a trench area. This contributed to chemical erosion of the pipe structure which lead to the nitrogen gas leak.

The ASME B31.3 Process piping, CGA G 5.4 2010 Standard for hydrogen piping systems at user locations, NFPA 2, hydrogen technologies code, NFPA 55, compressed gases, and cryogenic fluid codes were all ignored at the Gallatin facility. These codes require specific placement and maintenance of these types of gas lines and the Hoeganaes facility did no such regular inspection or consideration of their placement. The design and maintenance of this trench should have addressed the issue of slow corrosion over time caused by the hot water draining into it from the furnaces as well as solids accumulation. (Brauer, 2016)

Taking into consideration of these investigation findings the likelihood of an injury occurring during operations is likely to very likely equaling a level of risk of 20 to 25, which is reflective of the events that occurred in 2011. The severity rating for operational injury probability is rated at 5, which indicates an unaccepted rating for operational usage in the workplace and that some degree of control needs to be implemented in order to reduce this rating.

Once again the major variables that needed to be overcome at this facility center around lack of management oversight and consideration for worker safety, failure to meet many of the established regulatory standards, a lack of training and/or education on work hazards associated with PM, no written procedure or protocol to mitigate gas leaks including pre-site atmosphere testing, and failure to regulate any sort of preventative maintenance that would remove accumulated iron dust around the facility, exposed wiring, engineering controls which reduce occurrences of fire emergencies. Additionally, the minimal housekeeping controls that were being used proved to be ineffective. The iron dust coated nearly every surface up to 4 inches deep and was visible in the air. (Brauer, 2016) OSHA regulations require that each working surface be cleared of debris, including solid and liquid waste, at the end of each work shift, to benefit from a clean workplace environment, it is recommended that good housekeeping be maintained throughout the course of the job and workday. (United States Department of Labor (DOL), 2019)

To correctly assess the regulatory requirements that were ignored at this plant OSHA standards must be listed in order to effectively illustrate the level of negligence that lead to the 2011 incidents. All OSHA standards fall under the 29 CFR 1910 general industry standard and include 1910.38 Emergency action plans, 1910.39 Fire Prevention Plans, 1910 Subpart G, Occupational Health and environmental controls 1910.94 Ventilation, 1910 Subpart H Hazardous Materials including 1910.101 Compressed Gasses, 1910.103 Hydrogen; 1910.119 PSM; 1910.120 HAZWOPER; 1910 Subpart L Fire protection (all of it), 1910.178 Powered Industrial Trucks, and the 1910.1200 Hazard Communication standard.

“The three accidents at the Hoeganaes facility were entirely preventable. Despite evidence released by the CSB and information that Hoeganaes had in its possession even before the first accident in January 2011, the company did not institute adequate dust control or housekeeping measures,” said CSB Chairperson Rafael Moure Eraso. (Walter, 2012) If I was hired as a safety officer at this facility after the third reported incident, I would first recommend a complete shutdown of operations until all remnants of the accumulated iron dust were safely removed and stored in accordance with the NFPA 484 standard. Upon completion of this task, I would have the infrastructure updated to comply with the building construction section of the NFPA where I could insist on direct oversight from an auditor from the NFPA to ensure that the

Hoeganaes facility was up to code for manufacturing of combustible PM. Once these initial measures were initiated, I would recommend that all personnel undergo a thorough training regimen that included: lockout/tagout procedures, hazard communication, near-miss reporting and investigation procedures, electrical safety, fire safety, emergency action planning, fire protection planning, PPE training, and HAZWOPER 40hr training. Additionally, I would implement a preventative maintenance program with a schedule to ensure that each shift’s good practices are followed, including housekeeping procedures. Next, I would require bimonthly audits of the installed programs and equipment to ensure the effectiveness and safety of operations for the first year, whereupon successful implementation of a quarterly audit would occur. Next, I would work directly with the local fire department and/or fire chief to perform external safety audits of all PM operations at least biannually.

The NFPA life safety codes applicability to this facility would include regular fire drills focused on egress routes during a dust explosion. These drills would be illustrated and communicated to all affected employees in the plant operations through a fire emergency plan. Next installation of fire alarms and smoke detectors throughout the facility with regular inspections would be mandatory. A major part of the life safety code would be the addition of a fire suppression system in addition to appropriate portable fire extinguishers. Both systems shall be appropriate for the facility and operations that occur. A major addition would be the focus on facility fire safety in general where all applicable requirements and practices to ensure employee safety have been addressed and regularly trained on.

Reference

Brauer, R. L. (2016). Safety and health for engineers (3rd ed.). Hoboken, NJ: Wiley. U.S. Chemical Safety and Hazard Investigation Board. (2011). Hoeganaes Corporation: Gallatin, TN Metal Dust Flash Fires and Hydrogen Explosion, No. 2011-4-I-TN

Combustible dust explosion and fire case studies. (2014, April 24). Retrieved from https://www.ishn.com/articles/98438-combustible-dust-explosion-and-fire-case-studies

Goetsch, D. L. (2019). Occupational safety and health for technologists, engineers, and managers. NY, NY: Pearson.

Implementing a near-miss reporting system. (2015, January 27). Retrieved from https://www.safetyandhealthmagazine.com/articles/11735-implementing-a-near-miss-reporting-system

Ralitsa_Peycheva. (2019, May 07). Preventive Maintenance: 6 Elements of a Successful Program. Retrieved from https://www.mobility-work.com/blog/6-elements-successful-preventive-maintenance-program

UNITED STATES DEPARTMENT OF LABOR. (2019). Retrieved from https://www.osha.gov/dts/maritime/sltc/ships/housekeeping/intro.html

Walter, L. (2012, April 13). CSB: Dust Control, Housekeeping Failures Led to Fatal Hoeganaes Explosions. Retrieved from: https://www.ehstoday.com/fire_emergencyresponse/news/CSB-fatal-Hoeganaes-explosions-0110

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Identify a historic fire where the findings discussed a failure of having an installed fire protection system and/or egress issues resulting in a loss of life. Give a summary of the fire and elaborate on the findings. For the final part, discuss what is known today that could have prevented the tragedy.

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