Friday, January 30, 2015

Establishing Fire Protection and Life Safety Objectives

From The Code Coach:

Establishing Fire Protection and Life Safety Objectives

What is the purpose of a fire inspection program?  Why do fire prevention bureaus exist? 
For what reasons do fire protection and code consultants exist?  How can you know if your prevention program is accomplishing its objectives?

In 1975 the American Insurance Association published "Special Interest Bulletin No. 5, The Value and Purpose of Fire Department Inspections".  This bulletin outlined 7 objectives for an inspection program.  As you examine these objectives, evaluate your department, company, or organization and determine whether you are meeting these objectives, which of these you are great at, and which objectives need more of your attention.

  1. To obtain proper life safety conditions. 
  2. To keep fires from starting.
  3. To keep fires from spreading.
  4. To determine adequacy and maintenance of fire protection systems.
  5. To preplan fire fighting procedures.
  6. To stimulate cooperation between owners, occupants, and fire departments.
  7. To assure compliance with fire protection and life safety codes, standards, and regulations.

Proper life safety conditions
can be obtained by evaluating the adequacy of exits, protecting the path of egress, making sure that building evacuation plans are current, and determining occupant loads of the space.

Fires can be
prevented by monitoring the hazards associated with a facility or process.  Many people in the work force become complacent as they conduct their daily responsibilities without incident.  Public education, therefore, becomes an essential component to keep fires from starting.

The general public passes through our buildings everyday, largely unaware of the life saving features that surround them. Structural features such as enclosures, fire walls, fire partitions, and fire doors must be inspected and maintained to adequately keep fires from spreading.

There are three primary reasons that a fire sprinkler may fail. The top reason that sprinkler systems fail is due to a lack of maintaining operational status of the system, this can be followed up by inadequate or incomplete coverage of the fire area or hazard to be protected. The final reason a sprinkler may fail is inadequate performance of the system itself.  Any prevention program or fire strategy should include components that are designed to determine the adequacy and maintenance of the fire protection systems.

The best way to ensure success when fighting a building fire, saving lives, and preserving property is to preplan fire fighting procedures.  Fire protection programs should provide a clear layout of the building, its systems, related hazards, and special procedures or

Fire prevention bureaus should work closely with the public and establish a good relationship with the building owners and facility managers within their jurisdiction.  If a client is seeking the services of a fire protection or life safety consultant, a major part of the proposal should include a clear plan that outlines how cooperation between owners, occupants, and fire departments will be achieved.

With the myriad codes, standards, and regulations that abound, a fire prevention program should educate, interpret, and enforce these requirements.  With the constant submission of new code change proposals, and the creation  of new products and fire protection methods a skilled fire strategist will be knowledgeable enough to assure compliance with fire protection and life safety codes, standards, and regulations is met and maintained.

Does your fire inspection or life safety program address all of these objectives?  What
area needs more work?  What are some resources that you need to meet these objectives more efficiently?

Monday, January 26, 2015

How to contain aluminum dust

From Auto News:

 NADA » NADA Convention

How to contain aluminum dust?

Shops must put up curtain -- or a wall

Ford says a rubberized curtain will keep aluminum dust from settling on steel parts and corroding them. Some body shops say only a wall will do.

Published in Automotive News June 6, 2014

Curtains or walls? It's a big decision that Ford dealers with body shops face as they gear up to repair the 2015 aluminum-body F-150 pickup, arriving late this year.

Collision shops need either a curtain or wall to separate their aluminum body work from their steel body work. When aluminum dust ends up on a steel body part, a reaction called galvanic corrosion can produce an effect similar to rust over time.

There is even a small risk of fire if aluminum dust comes in contact with a spark.
Ford says floor-to-ceiling curtains, ventilation systems and special vacuums are sufficient to keep the metals from mixing, and some dealers and independent repair shops have decided to go that route.

Randall Reed, CEO of World Class Automotive Group of Dallas, says: "We are actually doing curtains in all five of the body shops.

"I think it's very sufficient, and with the vacuum system should be just fine."

Safety risk

But others want walls.

Todd Hoffman, vice president of Hoffman Ford in Harrisburg, Pa., says: "We're going to build the walls up. We may actually expand to a whole different location off site for a body shop. From what we're understanding from the big players in the paint business and body repair, it is a pretty significant safety risk to mix steel and aluminum."Speaking to Automotive News earlier this year, Paul Massie, Ford's collision marketing manager, said: "One of the things about our program that surprised the industry is that we didn't require a separate clean room."

Ford has said repeatedly that curtains provide sufficient separation. 
Larry Smith, president of Autometric Collision, said that two of his nine independent body shops in the Detroit area work on aluminum vehicles for luxury manufacturers including Audi, Mercedes-Benz and Porsche.

Both of Smith's shops cordon off the aluminum work areas with curtains.
Smith's shops will be doing repairs on the aluminum F-150.

"Most of the manufacturers that have aluminum vehicles are satisfied that's going to be enough to keep the steel and aluminum dust from settling on the wrong species of cars," Smith says.
But as the volume of aluminum vehicles increases, Smith plans to have more permanent work areas in place.

He owns several buildings that could be converted to aluminum work centers that will be separate from the shop areas where his company works on steel vehicles.

'Not the sound way'

Lloyd Schiller, a consultant who advises dealerships on their service operations, is urging his clients to build walls.

"Rubberized curtains are not the sound way to keep the dust from comingling. Essentially, it's a very heavy duty shower curtain. The idea behind having only curtains is to separate steel filings and dust from aluminum filings and dust. I'm sure it will keep 70 to 80 percent of it from escaping, but there's still an opportunity for some of the dust to escape when it's not a sealed unit."

Schiller says erecting walls need not be an expensive proposition.

The dealerships can simply put up a galvanized steel wall with drywall or pressed particleboard panels.

"You're not talking about a structural wall with concrete blocks and bricks. There may come a time five years from now when everything you're doing is aluminum, and you tear that wall down."
Meanwhile, collision shops need to remove aluminum dust from the air to prevent fires and explosions.

"Aluminum dust in the correct concentration is explosive if it comes in contact with an ignition source," says Jason Bartanen, director of industry-technical relations for I-CAR, the nonprofit collision repair group that is organizing F-150 repair training for Ford dealers and independent collision shops.

Ford wants dealers to purchase special sparkless vacuums for collision shops.

Ford spokeswoman Elizabeth Weigandt says the company has reminded dealers and technicians that airborne dust, "from metals to wood, can be flammable, and proper ventilation practices should be followed."

By year end, Ford wants a network of about 1,500 aluminum-capable body shops, including about 800 dealerships and 700 independent shops. About half of Ford's 3,000 dealerships have body shops.
Ford maintains that most of its body shops are already capable of doing most repairs on the redesigned pickup.

But Ford is creating the Ford National Body Shop Network of dealers and independent shops capable of large structural repairs.

The network, whose members have the proper tools and training, will be Ford's conduit for insurance company repair referrals for the pickup.

You can reach Bradford Wernle at

Tuesday, January 20, 2015

Dust: Hidden Hazard Lurks

Dust: Hidden Hazard Lurks - From Chemical Processing

Dust: Hidden Hazard Lurks

Facility finds danger from accumulated dust and effectively addresses it

By Cyrus Fisher, Eli Lilly and Company

Combustible dust can pose a hidden hazard when accumulation occurs in unseen locations such as in mechanical spaces, above false ceiling, ventilation systems and dust collection systems. Such hazards may be particularly well hidden in certain pharmaceutical manufacturing facilities where use of clean rooms with surrounding mechanical areas are common and the scale of the equipment and facility
is relatively modest. Even small quantities of combustible dust may result in a dust cloud flash fire or an explosion capable of significant damage in a plant environment. Although events of this magnitude may not make headline news, the potential impact on an individual present during a flash fire could be life changing.

Figure 1. Inspection revealed that interior of dust collector contained an accumulation ½- to 1-in. thick.

So, here, I share an example that occurred at Eli Lilly and Company to show how combustible dust may become “hidden” within a dust collection system, and to describe a methodology for safe
combustible-dust removal, as well as actions that can prevent future problems.

This example comes from a pharmaceutical blending operation located in a typical clean room. Technicians are preparing to blend 110 kg of dried pharmaceutical powder. All surfaces within the
room are dust free and the polished stainless steel blender has just been cleaned. The technicians connect a small 2-in. ventilation trunk between the blender and a port on the clean room wall labeled “to dust collector.” The technicians then open the access cover of the blender and press a button to start the dust collector, which is located elsewhere. Seven bags, each containing 16 kg of dried powder, are charged to the blender through the opening. The technicians are wearing personal protective equipment (PPE) to prevent inhalation of the dust but no dust is observed outside the opening. When the product charge is completed, technicians turn off the dust collector and disconnect the 2-in. ventilation trunk. The trunk is visually clean. The self-contained blending operation completes normally. All equipment and the room itself then are cleaned in preparation for the next batch. Lastly, the technicians leave the clean room to check for accumulation of material in a small drum under the dust collector; the drum is empty as always. The technicians know the routine well; they have completed these tasks at least once a week for the last ten years.

By their training, the technicians understand the powder they are handling is a combustible dust. They know the minimum ignition energy (MIE) has been tested at approximately 200 mJ with an average particle size of 27 microns, which means the risk of ignition from an electrostatic discharge from personnel is greatly reduced, and personnel grounding isn’t required [1]. The electrical outlets and switches in the clean room look different from others in the area, and signs hang on the doors
indicating the room is electrically classified as Class II, Division II for combustible dust. If technicians observe a dust cloud for any reason (e.g., a dropped product bag), they are to immediately leave the area until the cloud settles. In general, technicians believe little if any dusting occurs during loading of product to the blender — a belief supported by the lack of dusting seen during blender loading and emptying the dust collector discharge drum.

The technicians and technical support personnel assumed that because no dust is coming out of the dust collector, no dust is going in. The assumption was widely believed to be true and even documented in a previously completed formal hazard review. The idea that dust accumulation might be possible simply did not occur to those supporting the blending operation.

In 2012, the facility initiated a hazard review process for all solids handled at the site. This included looking specifically at the dust accumulation risk for each operation. One recommendation stemming from this activity was for engineering to perform an internal inspection of the blending operation dust collector.

Prior to the inspection, the team reviewed available design information for the dust collector and field-verified all ductwork. The system was designed for an airflow of 500 ft3/min to ensure  sufficient capture velocity at the blender opening during loading. The ductwork in the field begins at the clean room wall, where the duct diameter increases from 2 in. to 4 in. and then transitions to a diameter of 6 in. immediately prior to a 15-ft vertical riser. The duct then travels horizontally several hundred feet through multiple mechanical rooms before reaching the dust collector inlet plenum. Portions of this ductwork run above false ceilings. At the inlet plenum, the 6-in. duct expands to a 1-ft × 3-ft rectangle at which point it enters the dust collector. That unit, which is 1 ft in diameter and 3 ft in length, contains four cartridge filters. The dust collector is equipped with a differential-pressure pulsation system to clear the filters under conditions of high pressure drop. At the bottom
of the dust collector, a manual slide gate valve leads to the aforementioned drum for dust disposal.

During the engineering inspection, the four cartridge filters were removed and found to be heavily loaded with dust. Internal inspection of the dust collector revealed ½-in.+ layers of dust settled on all horizontal surfaces including the inlet plenum (Figure 1). Samples were taken and submitted for particle-size and MIE testing. The average particle size of the material in the dust collector was 12 microns, half the size of the bulk powder loaded to the blender. That in itself isn’t surprising because
the dust collector air stream primarily captures fines churned up during blender loading. The MIE for the material in the dust collector was approximately 25 mJ — an order of magnitude less than that of the bulk powder loaded into the blender! With an MIE as low as 25 mJ, the risk of ignition from electrostatic discharges becomes a greater hazard,necessitating enhanced safeguards including personnel grounding [1].

Upon discovery of this fine collected dust, planning commenced for its removal. Engineering personnel led the effort and got assistance from maintenance and operations. The cleaning scope included both the main body of the dust collector and all impacted ductwork. Engineering
developed a written cleaning plan. A hazard review team then performed a risk analysis of the proposal. Hazard review teams are routine at this facility due to the significant quantities of solvents utilized. However, site personnel were relatively inexperienced with combustible dust remediation. To ensure a robust review, corporate combustible-dust subject matter experts and the contractors selected to perform the cleaning joined site engineering, operations, maintenance and health/safety personnel to perform a what-if risk analysis of the written cleaning plan.

Using photographs from the field, engineering went over the entire dust collection system with the review team. The MIE data obtained for the dust then were used to list types of ignition sources that would have sufficient energy to ignite a dust cloud if one formed during the cleaning operation. The hazard review team next focused on two specific areas for risk reduction: 1) identifying safeguards that would prevent/minimize/contain disruption of the dust to prevent formation of a combustible dust cloud during cleaning; and 2) identifying safeguards to minimize all possible ignition sources in the event a combustible dust cloud inadvertently was created.

To minimize the risk of creating a dust cloud, the cleaning plan incorporated multiple  recommendations from the hazard review team. First, the order of line breaks and cleaning activities
were specified so as to remove dust from easy-to-access areas prior to performing higher-risk line breaks. The goal was to remove as much fuel from the system as possible before performing overhead work with reduced egress options. This included removal of the filter elements and
cleaning of the dust collector prior to disassembling overhead ductwork. Second, extra ductwork supports were installed. Adding these supports ensured the ductwork couldn’t accidently fall as it was disassembled, disturbing settled dust and potentially forming an ignitable dust cloud. Third, plastic sheeting and glove bags (similar to those used for asbestos remediation) isolated rooms and line breaks. These actions ensured that any dust disturbed wouldn’t be able to travel outside the boundaries of the work area, where measures to enhance protection against ignition also were being put in place.

Potential ignition sources were categorized, e.g., charge on metal surfaces (scaffolding, ductwork, etc), charge on personnel, charge on tools, the vacuum to be used for cleaning, and surrounding
electrical equipment. Again, the cleaning plan incorporated multiple recommendations from the hazard review team. Grounding wires were installed in multiple predefined locations including the ductwork (Figure 2), dust collector, scaffolding and any other potentially isolated metal surface. Engineering inspected the contractor air-powered HEPA vacuum equipment. Prior to the cleaning, which took place in August 2013, all operating equipment in the work area was shut down, and
an extensive lock-out/tag-out was performed for all electrically powered equipment. Lock out of electrical equipment was accomplished remotely in motor control centers or at electric breaker panels away from the work area. Equipment locked out included motors, heaters, power outlets and control panels. Immediately prior to performing work, engineering met with contractors and maintenance personnel to review the cleaning plan, PPE requirements, and combustible dust hazards. All
personnel were instructed to leave the area in the event of a dust cloud. “Danger” tape isolated the entire area; technicians posted at all entrances kept personnel out of the cleaning area.

The planning and coordination for the cleaning activity took several weeks but the cleaning itself required less than six hours. Approximately 10 kg of combustible dust were removed from the system and collected as a wet paste in the bottom of the contractor’s vacuum equipment. After cleaning, engineering inspected all ductwork, which was in like-new condition.

Engineering initiated a root cause investigation into why dust had accumulated and what needed to be implemented to stop accumulation from occurring in the future. The root cause investigation identified two causal factors.

First, designers had inaccurate/incomplete process safety information when the dust collection system was installed over a decade prior to this event. Preliminary design documentation erroneously indicated the product wasn’t combustible. As a result, the dust collector system design didn’t
incorporate standards applicable to combustible dust (isolation/suppression systems, housekeeping program, etc.).

Second, multiple opportunities to identify the risk of accumulating material were missed even after the material was confirmed to be combustible. One opportunity came after several years of service when an initial combustible-dust hazard assessment was completed on the blending operation/dust collector. At the time, the facility had minimal organizational knowledge regarding combustible dust hazards. Technicians interviewed then stated that little dusting occurred during loading of the blender and no dust ever was discharged from the dust collector. These types of observations prompted the review team to conclude that no dust was being pulled into the dust collector system. The root cause
investigation found these observations/conclusions to be inaccurate. The lack of dusting at the blender was due to the successful operation of the dust collector (i.e., dust is pulled away from the operator as intended). The failure to discharge material from the dust collector was traced to a mechanical problem with the internal pulsation system, which likely never had functioned following initial installation. This explained the heavy loading seen on the filters.

Another opportunity to recognize that dust was accumulating arose during completion of routine airflow testing. The investigation found that a 50% drop in airflow was documented in the work history of the dust collector but not flagged as a potential dust-collector operations issue. The reduced airflow rate of 250 ft3/min sufficed to maintain operator protection from an industrial hygiene perspective, so no actions were taken to restore the airflow to the original design requirement of 500 ft3/min. The reduced flow and, thus, duct velocity accelerated accumulation. Generally, preventing the settling of materials similar to this product requires a minimum airflow rate of 2,500 ft/min [2]. At 250 ft3/min, the dust collector system was operating well below this minimum velocity in the 6-in.-diameter line that accounted for the majority of the ductwork in the system. In some cases, nearly 50% of the duct cross-sectional area was found to be plugged, particularly near the bottom of vertical risers where dust settling was prevalent.

Recommendations from the root cause investigation included: upgrading the system design to be suitable for combustible dust service; implementing routine internal inspections; establishing pass/fail criteria for duct velocity measurements; modifying duct sizing to increase airflow velocity; and setting up a program for regular internal cleaning.

The key takeaways from our experience are:

• Accurate material properties are essential for making informed risk-based decisions whenever handling combustible dust. The properties of a specific combustible dust material can vary greatly with changes in particle size. In our case, a 50% reduction in particle size resulted in an order-of-magnitude decrease in MIE and, thus, a far greater risk of a combustible dust flash-fire/explosion. Failure to understand this reduction in MIE might have resulted in less-stringent safeguards during
development of the cleaning plan.

• Having all affected parties and subject matter experts take part in performing a thorough hazard
analysis is invaluable in confirming that a written plan provides the safest possible path forward for executing a non-routine activity.

• An effective prework safety meeting ensures work is completed in the manner intended by the hazard review team and also provides a final opportunity to address concerns of those performing the work.

In the end, a significant amount of resources went into the uneventful cleaning of a small quantity of accumulated material. The results of the cleaning activity and subsequent investigation were communicated in multiple forums across the organization. Many committed team members actively participated in completing this work. Hopefully, this simple example results in positive outcomes for others vigilantly working to reduce combustible dust risk.

CYRUS FISHER is a consultant engineer for Eli Lilly and Company, Indianapolis, IN. E-mail him at

1. “NFPA 77 – Recommended Practice on Static Electricity,” 2014 ed., National Fire Protection Assn., Quincy, MA (2013).
2. “Industrial Ventilation,” 25th ed., American Conf. of Governmental Industrial Hygienists, Cincinnati, OH (2004).

Monday, January 19, 2015

mistakes led to a dangerous fire at ink factory involving combustible dust

"the design and installation of the new dust collection system was done so poorly that it overheated within a few days of being activated, ignited spontaneously and caused an explosion that then released a fireball on seven workers."

The Record: Worker safety

January 18, 2015
   Last updated: Sunday, January 18, 2015, 1:21 AM

A US Ink worker being treated by an EMT after the explosion in 2012.

A US Ink worker being treated by an EMT after the explosion in 2012.

A FEDERAL investigation found that a series of mistakes led to a dangerous fire at an East Rutherford ink factory involving combustible dust in 2012. New Jersey needs stronger regulations to avoid potential disasters in the future.

The U.S. Chemical Safety and Hazard Investigation Board, an independent federal agency that looks at industrial chemical accidents and makes recommendations to governing bodies, released a report
Thursday detailing the problems at the US Ink facility. According to the report, the design and installation of the new dust collection system was done so poorly that it overheated within a few days of being activated, ignited spontaneously and caused an explosion that then released a fireball on seven workers.

Thankfully, no one died; the investigation showed that steps should have been taken to significantly increase the safety of the operation.

"The new system was not thoroughly commissioned. There was no confirmation of whether the system would work as configured, missing opportunities to find potential hazards," investigation supervisor Johnnie Banks said. "The design flaws were not revealed until the dust explosion."

Staff Writer James M. O'Neill reported that another avoidable problem was that the workers were not wearing flame-resistant clothing, even though the Occupational Safety and Health Administration requires that when there are flash fire or explosion hazards.

The investigation showed that US Ink didn't apply for a building permit because it thought a New Jersey building code exemption applied to the equipment. This is where the state needs to act on the CSB's recommendations.

There must be tighter regulations on dust-handling equipment. According to the investigation, New Jersey's current rules exempt "manufacturing, production and process equipment" from higher national fire-protection standards.

Rafael Moure-Eraso, the agency's chairman, said there have been at least 50 incidents involving combustible dust at facilities across the country, killing 29 workers and sending 161 to the hospital, between2008 and 2012. "We consider this to be a national problem," he said.

The agency also wants the state to train local safety officials on the national fire protection standards for combustible dust, since they are the ones making inspections at the facilities.

Increasing the thoroughness of inspections on this industry should not be seen as a burden. The people at risk here are the companies' employees, as well as local officials and emergency responders, who will have to deal with the consequences when a fiery incident like the 2012 one occurs.

Employees at US Ink suffered first- and second-degree burns and eventually returned to work. The next time this happens, the situation could be even more tragic.

Thursday, January 15, 2015

Poor Design and Failure to Test Dust Collection System Among Causes of U.S. Ink Flash Fire

From U.S. Chemical Safety Board

CSB - U.S. CHEMICAL SAFETY BOARD -- An independent federal agency investigating chemical accidents to protect workers, the public, and the environment

CSB Names Poor Design and Failure to Test Dust
Collection System Among Causes of U.S. Ink New Jersey Flash Fire that
Burned Seven Workers in 2012;

OSHA Again Urged to Issue New Combustible Dust Regulations  
East Rutherford, New Jersey, January 15, 2015—The flash fire that burned seven workers, one seriously, at a U.S. Ink plant in New Jersey in 2012 resulted from the accumulation of combustible dust inside a poorly designed dust collection system that had been put into operation
only four days before the accident, an View of Dust Collector at US Ink investigation by the U.S. Chemical Safety Board (CSB) has found.

In a report released today
and scheduled to be presented for board consideration at a CSB public
meeting in East Rutherford this evening, the investigation team
concludes that the system was so flawed it only took a day to accumulate enough combustible dust and hydrocarbons in the duct work to overheat, ignite spontaneously, cause an explosion in the rooftop dust collector,
and send back a fiery flash that enveloped seven workers.

U.S. Ink is a subsidiary of Sun Chemical, a global graphic arts corporation which has some 9,000 employees worldwide. U.S. Ink manufactures black and color-based inks at seven U.S. locations
including East Rutherford. A key step in the ink production process is mixing fine particulate solids, such as pigments and binders, with liquid oils in agitated tanks.

CSB Chairperson Rafael Moure-Eraso said, “The findings presented in the CSB report under consideration show that neither U.S. Ink nor its international parent company, Sun Chemical, performed a thorough hazard analysis, study, or testing of the system before it was commissioned in
early October 2012. The original design was changed, the original company engineer retired prior to completion of the project, and no testing was done in the days before the operation of the black-ink
pre-mixing room production was started up.”

The CSB found that the ductwork conveyed combustible, condensable vapors above each of three tanks in the mixing room, combining with combustible particles of dust of carbon black and Gilsonite used in the production of black ink.

Investigation Supervisor Johnnie Banks said, “The closed system air flow was insufficient to keep dust and sludge from accumulating inside the air ducts.  But to make matters worse, the new dust collector design included three vacuuming hoses which were attached to the closed-system
ductwork, used to pick up accumulated dust, dirt and other material from the facility’s floor and other level surfaces as a ‘housekeeping’ measure.  The addition of these contaminants to the system ductwork doomed it to be plugged within days of startup.”

The report describes a dramatic series of events that took place within minutes on October 9, 2012.  About 1 p.m., an operator was loading powdered Gilsonite, a combustible carbon-containing mineral,
into the bag dump station near the pre-mixing room when he heard what he called a strange, squealing sound.  He checked some gauges in the control room, and as he was leaving he saw a flash fire originating from the bag dump where he had just been working.  He left to notify his supervisor.  At about that same time, other workers heard a loud thump that shook the building.

In response to the flash from the bag dump station and the thump, workers congregated at the entrance to the pre-mix room.  One worker spotted flames coming from one of the tanks.  He obtained a fire extinguisher but before he could use it, he saw an orange fireball erupt and advance toward him.  He squeezed the handle on the extinguisher as he jumped from some stairs, just as the flames engulfed him and six other employees who were standing in the doorway.

The CSB determined that overheating and spontaneous ignition which likely caused the initial flash fire at the bag dump was followed by ignition of accumulated sludge-like material and powdery dust mixture of Gilsonite and carbon black in the duct work above tank 306.  Meantime, the dust collection system, which had not been turned off, continued to move burning material up toward the dust collector on the building’s roof, where a sharp pressure rise indicated an imminent explosion. This was contained by explosion suppression equipment, but the resulting pressure reversed the air flow, back to the pre-mix room, where a second flash fire occurred, engulfing the workers.

Investigation Supervisor Banks said, “The new system was not thoroughly commissioned.  There was no confirmation of whether the system would work as configured, missing opportunities to find potential hazards.  The design flaws were not revealed until the dust explosion.”

The report’s safety management analysis points to a lack of oversight by company engineers of the work done by installation contractors. The company chose not to perform a process hazard analysis or management of change analysis – required by company policy for the installation of new
processing equipment – because it determined it was merely replacing a previous dust collection system in kind.  However, the new system in fact was of an entirely different design.

Considering the emergency response following the flash fire and dust collector explosion, CSB Investigators found that while workers had received training in emergency response situations, they did not follow those procedures, because U.S. Ink had not developed and implemented an
effective hazard communication and response plan.  A fire coordinator was designated to use the public address system to announce a fire and also pull the alarm box. But because the system was not shut down immediately after the first flash fire, he was among the injured and could not perform his duties.

The CSB report’s regulatory analysis highlights the need for a national general industry combustible dust standard which the agency has long recommended that OSHA promulgate, putting in on the CSB’s “Most Wanted” list in 2013, following years of urging action as dust explosions continued to occur in industry.  The report, if adopted by the board, would reiterate the CSB’s original  recommendation to OSHA, and also recommend OSHA broaden the industries it includes in its
current National Emphasis Program on mitigating dust hazards, to include printing ink manufacturers.

Chairperson Moure-Eraso said, “Although OSHA’s investigation of this accident deemed it a combustible dust explosion, it did not issue any dust-related citations, doubtless hampered by the fact that there is no comprehensive combustible dust regulatory standard.  In U.S. Ink’s case –
and thousands of other facilities with combustible dust – an OSHA standard would likely have required compliance with National Fire Protection Association codes that speak directly to such critical factors as dust containment and collection, hazard analysis, testing, ventilation, air flow, and fire suppression.”

The CSB report notes that the volume of air flow and the air velocity in the company’s dust collection system was significantly below industry recommendations – which, in the absence of a federal
combustible dust regulation, are essentially voluntary.  The report states the ductwork design did not comply in several respects with guidelines set by the American Conference of Governmental Industrial Hygienists (ACGIH) Industrial Ventilation Manual.  Nor did the system’s design, the CSB said, comply with the voluntary requirements of NFPA 91, which states: “All ductwork shall be sized to provide the air volume and air velocity necessary to keep the duct interior clean and free of residual material.”

Chairperson Moure-Eraso said, “A national combustible dust standard would include requirements to conform to what are now largely voluntary industry guidelines and would go far in preventing these dust explosions.”

The report cites gaps in New Jersey’s regulatory system, noting the state’s Uniform Construction Code Act has adopted the International Building Code (which references NFPA dust standards) but has also exempted “manufacturing, production and process equipment.”  A proposed CSB recommendation to New Jersey’s Department of Community Affairs calls on the regulatory agency to revise the state’s administrative code to remove this exemption so that dust handling equipment would be designed to meet national fire code requirements.  The state is also urged to implement training for local code officials as local jurisdictions enforce the code, and to promulgate a regulation that requires all occupancies handling hazardous materials to inform the local enforcement agency of any type of construction or installation of equipment at an industrial or manufacturing facility.

Chairperson Moure-Eraso said, “Events leading to this accident began even before the earliest planning stages, when the company failed to properly oversee the design, construction and testing of a potentially hazardous system.  The victims have suffered the consequences.  We hope our recommendations are adopted so that these terrifying industrial dust explosion accidents will stop.”

The CSB is an independent federal agency charged with investigating industrial chemical accidents. The agency's board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit our website,

For more information, contact Communications Manager Hillary Cohen, cell 202-446-8094 or Sandy Gilmour, Public Affairs, cell 202-251-5496.