Apr 10, 2007
CSB Issues Final Report on Universal Form Clamp Explosion and Fire in Bellwood, Illinois; Investigation Notes Mixture Overheating, Inadequate Plant Design, Lack of Emergency Action Plan Led to Death and Injuries
Chicago, Illinois, April 10, 2007 - An explosion and fire took the life of a contract delivery driver and injured two employees at the Universal Form Clamp (UFC) plant in Bellwood, Illinois, on June 14, 2006. The explosion occurred when hazardous vapors, generated by overheating a flammable liquid in an open-top tank, ignited, the U.S. Chemical Safety Board (CSB) found in a Case Study issued today.
The CSB said the Universal Form Clamp plant process was not designed and constructed in accordance with fire safety codes and Occupational Safety and Health Administration (OSHA) standards, which required (among other things) that they have a ventilation system to control flammable vapors. Investigators determined UFC was unprepared for an accidental chemical release of this magnitude, did not have an emergency action plan, and had not conducted an evacuation drill.
The company manufactures hundreds of products for the concrete industry, and added the chemical mixing area to produce two specialty products in 2002 and 2003.
The CSB found the mixture likely overheated because a mixing tank temperature controller was not installed or maintained in accordance with the manufacturer's specifications, causing it to malfunction. As the temperature of the flammable mixture increased to its boiling point, vapors overflowed the open top tank, and spread along the floor throughout the mixing area and surrounding workplaces.
The worker notified a senior operator of the vapor cloud, and the operation was shut down. Both men exited the building and advised workers in the adjoining areas to leave. Other workers left because they saw or smelled the vapor cloud. There was no alarm system to warn employees to evacuate.
A delivery driver, unaware of the hazard, walked into the building past employees who had left the building. Witnesses said they attempted to alert him to the presence of the vapor cloud, but said he was talking on a cell phone and may not have heard them. Shortly after the driver walked into the area, the vapor cloud ignited creating a large fireball. The driver died several days later from burns. A temporary employee, in an adjacent area, unaware of the hazard, suffered second-degree burns and was hospitalized. A third employee suffered a minor injury to his arm.
CSB Lead Investigator Randy McClure said, "This accident could have been avoided had the company complied with OSHA and NFPA fire safety standards, which require engineered safety controls such as local exhaust and floor-level ventilation systems. In addition, there likely would have been no fatality or injuries had the company installed an employee alarm system, put adequate emergency action plans in place, and conducted regular emergency drills so that employees knew what to do in an emergency."
The CSB determined that mechanical design plans that should have illustrated ventilation and other safety systems were not reviewed by a registered design professional before being submitted to the Village of Bellwood. In addition, Bellwood, during its 2002 review of the project, did not ensure compliance with required codes and standards.
CSB Board Member Gary L. Visscher said, "The CSB Case Study cites several lessons learned that we believe could help prevent accidents at similar facilities if studied and applied. These include the importance of having qualified professionals manage the design and construction of facilities using flammable liquids, the need for comprehensive building permit code reviews, and the need for emergency action plans."
The CSB also made two recommendations to OSHA regarding its emergency action plan requirements. The first recommends OSHA amend its Flammable and Combustible Liquids standard to require facilities that handle these liquids to implement the requirements of its Emergency Action Plans standard. As it is currently written, the Flammable and Combustible Liquids standard covers technical issues pertaining to facility design, but does not contain a requirement for companies to have Emergency Action Plans.
Additionally, the CSB recommended OSHA amend the Emergency Action Plans standard to require employers to conduct practice evacuation drills at least annually, but more frequently if necessary to ensure employees are prepared for emergencies. Currently this standard does not specifically require such drills or rehearsals.
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, www.csb.gov.
For more information, contact Sandy Gilmour, cell 202-251-5496, or Public Affairs Specialist Kate Baumann, cell 202-725-2204.