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Hoeganaes Corporation Fatal Flash Fires
FINAL REPORT: Hoeganaes Corporation
Location: Gallatin, TN
Accident Occurred On: 01/31/2011
Final Report Released On: 01/05/2012
Accident Type: Combustible Dust Explosion and Fire
Company Name: Hoeganaes Corporation

statistics

Total # of Recommendations
13
Total # of Open Recommendations
9
Total # of Closed Recommendations
4
Total % of Open 69 vs. Closed 31

investigation information

Image
Accident Description
Three combustible dust incidents over a six month period occurred at the Hoeganaes facility in Gallatin, TN, resulting in fatal injuries to five workers. The facility produces powdered iron and is located about twenty miles outside of Nashville.
Investigation Status
The CSB's investigation was approved by the board on December 16, 2011. The case study was released at a news conference in Nashville, TN, on January 5, 2012.


 

Recommendations

City of Gallatin, TN
2011-4-I-TN-11

Require all facilities covered by IFC Chapter 13 (2006 edition) to conform to NFPA standards for combustible dusts including NFPA 484.

Status: Open - Acceptable Response or Alternate Response
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

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City of Gallatin, TN Fire Department
2011-4-I-TN-12

Ensure that all industrial facilities in the City of Gallatin are inspected periodically against the International Fire Code. All facility inspections shall be documented.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

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2011-4-I-TN-13

Implement a program to ensure that fire inspectors and response personnel are trained to recognize and address combustible dust hazards.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

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Hoeganaes Corporation
2011-4-I-TN-6

Conduct periodic independent audits of the Hoeganaes Gallatin facility for compliance with the following NFPA standards, using knowledgeable experts, and implement all recommended corrective actions:

  • NFPA 484, Standard for Combustible Metals, Metal Powders, and Metal Dusts
  • NFPA 499, Recommended Practice for the Classification of Combustible Dusts and of Hazardous Locations for Electrical Installations in Chemical Process Areas
  • NFPA 497, Recommended Practice for the Classification of Flammable Liquids, Gases, or Vapors and of Hazardous (Classified) Locations for Electrical Installations in Chemical Process Areas
  • NFPA 2, Hydrogen Technologies Code
  • NFPA 2113, Standard on Selection, Care, Use, and Maintenance of Flame-Resistant Garments for Protection of Industrial Personnel Against Flash Fire

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2011-4-I-TN-7

Develop training materials that address combustible dust and plant-specific metal dust hazards and train all employees and contractors. Require periodic (e.g., annual) refresher training for all employees and contractors.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2011-4-I-TN-8

Implement a preventive maintenance program and leak detection and leak mitigation procedures for all flammable gas piping and gas processing equipment.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2011-4-I-TN-9

Develop and implement a near-miss reporting and investigation policy that includes the following at a minimum:

  • Ensure facility-wide worker participation in reporting all near-miss events and operational disruptions (such as significant iron powder accumulations, smoldering fires, or unsafe conditions or practices) that could result in worker injury.
  • Ensure that the near-miss reporting program requires prompt investigations, as appropriate, and that results are promptly circulated throughout the Hoeganaes Corporation.
  • Establish roles and responsibilities for the management, execution, and resolution of all recommendations from near-miss investigations
  • Ensure the near-miss program is operational at all times (e.g. nights, weekends, holiday shifts).

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

International Code Council (ICC)
2011-4-I-TN-4

Revise IFC Chapter 22 Combustible Dust Producing Operations; Section 2204.1 Standards, to require mandatory compliance and enforcement with the detailed requirements of the NFPA standards cited in the chapter, including NFPA 484.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Metal Powders Producers Association (MPPA)
2011-4-I-TN-10

Communicate the findings of this report to all your members, e.g. through a safety article in an upcoming monthly newsletter.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Occupational Safety and Health Administration (OSHA)
2011-4-I-TN-1

Ensure that the forthcoming OSHA Combustible Dust Standard includes coverage for combustible metal dusts including iron and steel powders.

Status: Open - Unacceptable Response
Open - Unacceptable Response (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

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2011-4-I-TN-2

Develop and publish a proposed combustible dust standard for general industry within one year of the approval of this case study.

Status: Open - Unacceptable Response
Open - Unacceptable Response (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

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2011-4-I-TN-3

Revise the Combustible Dust National Emphasis Program (NEP) to add industry codes for facilities that generate metal dusts (e.g., North American Industrial Classification System, NAICS, code 331111 Iron and Steel Mills, and other applicable codes not currently listed). Send notification letters to all facilities nationwide under these codes to inform them of the
hazards of combustible metal dusts and NEP coverage.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Tennessee Division of Occupational Safety & Health (TOSHA)
2011-4-I-TN-5

Revise the state-adopted Dust National Emphasis Program (NEP) to add industry codes for facilities that generate metal dusts (e.g., North American Industrial Classification System, NAICS, code 331111 Iron and Steel Mills, and other applicable codes not currently listed). Send notification letters to all facilities statewide under these codes to inform them of the
hazards of combustible metal dusts and NEP coverage.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

 
 

Related Video

Iron in the Fire
1/5/2012 3:00:00 PM
Three iron dust fires in 2011 fatally injure 5 workers in Gallatin, TN. read more

Download QuickTime Video
Dust Testing Dust Testing
6/3/2011 2:00:00 PM
Video from combustible metal dust testing conducted by the U.S. Chemical Safety Board (CSB). read more

Related News

U.S. Chemical Safety Board Determines OSHA Response to Seven Open CSB Recommendations on Dust, Fuel Gas, and Process Safety Management to be “Unacceptable;” Board Votes to Designate a Combustible Dust Standard as “Most Wanted”
7/25/2013
U.S. Chemical Safety Board Determines OSHA Response to Seven Open CSB Recommendations on Dust, Fuel Gas, and Process Safety Management to be “Unacceptable;” Board Votes to Designate a Combustible Dust Standard as “Most Wanted”
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