Federal regulators, state inspectors and company officials did not take steps that could have prevented a December 2010 explosion and fire that killed three workers at a Hancock County metals recycling plant, U.S. Chemical Safety Board investigators have concluded.
The deaths at AL Solutions in New Cumberland were another in a string of "combustible dust explosions and fires that the CSB says show the clear need for a new federal standard that's been repeatedly delayed by the Obama administration's Occupational Safety and Health Administration.
In a report made public Wednesday, CSB investigators also found OSHA did not include AL Solutions in a special inspection program, despite the facility's history of fires, and that the West Virginia Fire Marshal "does not regularly inspect industrial operations to ensure compliance with fire codes that address control of dust in combustible metals facilities.
Two brothers, Jeffrey Scott Fish and James Eugene Fish, and a third worker, Steven Swain, were killed by the fire and explosion at AL Solutions. The company operated a small plant on the banks of the Ohio River where it processed scrap titanium and zirconium metals into pressed "compacts that aluminum producer use as alloy additives.
Titanium and zirconium are both highly flammable, and CSB testing of dusts from both materials found "higher explosion severity, according to the agency's report. AL Solutions had a safety manual that listed several requirements for storing and handling the materials, but company management did not enforce those requirements, the CSB said.
Storage and process containers were left open, the facility had no dust collection system and AL Solutions had a water-based fire suppression system, despite the fact water could make a fire involving titanium or zirconium worse, the CSB report said.
CSB officials said their findings at AL Solutions were similar to those at multiple other combustible dust workplace disasters the agency has investigated in recent years.
The CSB has been urging OSHA to write a combustible dust rule since 2006, when the board issued a landmark report that detailed 281 such incidents between 1980 and 2005 that resulted in 119 deaths and 718 injuries. Between 2008 and 2013, the CSB has found 50 more incidents involving 29 deaths and 161 injuries.
In 2008, then-Sen. Barack Obama said that it was "long past time for OSHA to issue a combustible dust rule, and after his election, OSHA moved in April 2009 to being writing such a rule. But OSHA has never published a proposed rule, and has repeatedly delayed the next step in the rulemaking process - a meeting to collect information about the potential impacts on small businesses - and in May delayed any action on the issue again.
The CSB has called OSHA's inaction "unacceptable and made issuance of an OSHA combustible dust standard the first of the board's "most wanted actions to improve worker safety around the country. Like the National Transportation Safety Board, the CSB has no power to issue citations, levy fines or write new rules. It can only investigate accidents and recommend actions to prevent recurrences.
"Preventable combustible dust explosions continue to occur causing worker deaths and injuries, CSB Chairman Rafael Moure-Eraso says in a new video describing the AL Solutions incident. "The CSB believes it is imperative for OSHA to issue a comprehensive combustible dust standard & with clear requirements to prevent dust fires and explosions.
Board member Mark Griffon added, "It is very frustrating that we are here reporting on yet another combustible dust explosion. The time for action is now.
Jesse Lawder, a spokesman for OSHA, declined to comment on the CSB report, except to say that the agency plans to begin its review of a dust rule's potential impact on small businesses in December.
Mark Colantonio, a lawyer for the Fish family, said his clients were glad that the CSB completed its report.
"Maybe their findings will prevent something like this from happening in the future, Colantonio said.
According to the CSB's 37-page report, the AL Solutions incident occurred at about 1:20 p.m. on Dec. 9, 2010. An electrical contractor working outside the processing building told CSB investigators that he heard a loud "woof ... just like you'd light your gas grill and then a "big boom. Witnesses described a fireball moving through the building and said that the "air was sparking after the explosion.
CSB investigators believe the likely ignition point was a blender in which the milled metals were blended to meet sales specifications, and where metal blades repeatedly contacted the blender sidewall, igniting highly volatile zirconium. Agency investigators found that AL Solutions employees had noted problems with the blender in the days before the explosion.
"Blender paddles were striking the sidewall of the blender and scoring the housing, the CSB's report said. "To address these problems, maintenance personnel adjusted the blender blades to increase clearance from the blender wall, but this action did not permanently address the issue with the metal-to-metal contact.
"When the problem returned, maintenance personnel decided to replace parts of the blender in an effort to resolve the issue, the report said. "While the operators were disassembling the blender, they discovered a large groove cut in the shaft and an eight-inch to 12-inch crack in the sidewall of the blender, most likely caused by the paddle blades scraping the sidewall. The maintenance worker welded this crack, and operators continued to use the blender.
On the morning of the incident, an operator requested that maintenance replace a worn paddle in the blender. A maintenance employee retrieved a paddle from an old blender and attached it to the blender about two hours before the explosion, the CSB said.
"All of the maintenance performed on the blender only temporarily addressed the problems caused by the metal-to-metal contact, such as the scoring on the sidewall and worn paddles, the CSB report said. "AL Solutions did not repair or replace the blender to avoid exposing combustible dust to sparks or heat produced by the mechanical impact from the paddles.
Before the 2010 incident, the AL Solutions facility had experienced two fatal explosions involving the ignition of metal dust. From 1993 until the December 2010 incident, the New Cumberland Volunteer Fire Department responded to at least seven fires at AL Solutions, according to the CSB report.
CSB investigator Mark Wingard said that the National Fire Protection Association Standard for combustible metals industries, called NFPA 484, recommends specific practices for control metal dust.
"But AL Solutions did not voluntarily follow those guidelines, and there are no federal OSHA standards to enforce similar requirements, Wingard said.
Since the 2010 deaths, AL Solutions has closed the New Cumberland operation and has a new production facility in Burgettstown, Pa. OSHA and the U.S. Environmental Protection Agency reached settlements that those agencies said required reforms that would reduce the risk of combustible dust incidents at that Pennsylvania facility and another company site in Washington, Missouri.
CSB investigator Lucy Tyler said that the improved safety measures included in the EPA and OSHA deals with AL Solutions appeared to line up with the sorts of recommendations the board made to the company.
AL Solutions declined comment on the CSB report.
The CSB report noted that prior to the 2010 deaths, OSHA's West Virginia office did not include AL Solutions in any inspections under a national program started in 2007 to emphasize the potential hazards of combustible dust. This inspections program targets sites based on a "randomized selection of facilities, regardless of previous incidents, unless initiated by a complaint or referral, according to the CSB.
Also, the CSB report noted that the West Virginia Fire Marshal has authority under state law to enforce national fire codes, which include provisions aimed at combustible dust safety.
"The State Fire Marshal holds the authority to dictate which repairs or changes are necessary to mitigate any fire hazard in a facility, the CSB report said. "However, the State Fire Marshal's Office does not regularly inspect buildings to ensure compliance with the State Fire Code.
The report noted that the Fire Marshal has 17 inspectors tasked with ensuring compliance for the entire state. A company can request an inspection by filling out a form online and paying $50, the CSB said. CSB officials made no recommendations for the Fire Marshal to step up such inspections, and board investigator Tyler said that previous CSB work has shown that putting the burden of combustible dust explosions on state fire agencies is probably not fair. "They just don't have the resources or the training, Tyler said.
Lawrence Messina, a spokesman for the state Department of Military Affairs and Public Safety, said that the Fire Marshal's office focuses its inspection efforts on buildings with "high-risk occupants, such as day-care centers, schools, hospitals and nursing homes. Messina said that the Fire Marshal looks to agencies like OSHA to inspect industrial facilities.
"It is therefore encouraging that the report calls on OSHA to develop a standard to prevent this type of accident from occurring in the future, Messina said in an email message.
Reach Ken Ward Jr. at firstname.lastname@example.org, 304-348-1702 or @kenwardjr on Twitter.
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