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Sterigenics Ethylene Oxide Explosion
Location: Ontario, CA
Accident Occurred On: 08/19/2004
Final Report Released On: 03/30/2006
Accident Type: Chemical Manufacturing - Fire and Explosion
Company Name: Sterigenics

statistics

Total # of Recommendations
17
Total # of Open Recommendations
0
Total # of Closed Recommendations
17
Total % of Open 0 vs. Closed 100

investigation information

Image
Accident Description
At approximately 3:00 p.m. on August 19, 2004, an explosion occurred inside an ethylene oxide sterilization chamber and an associated thermal oxidizer at the Sterigenics facility in Ontario, California. Four employees suffered minor injuries and the facility was rendered unusable.
Investigation Status
On March 30, 2006, the CSB issued its final report on the accident.


 

Recommendations

California Air Resources Board (CARB)
2004-11-I-CA-7

In collaboration with other state/regional agencies as necessary, such as California Occupational Safety and Health Administration, recommend to facilities that treat ethylene oxide backvent emissions with oxidizing emissions control devices to evaluate current process controls and install appropriate safeguards, such as: - Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. - Post-ignition deflagration detection and damage control devices.

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.
 

California Occupational Safety and Health Administration (Cal/OSHA)
2004-11-I-CA-8

In collaboration with other state/regional agencies as necessary, such as California Environmental Protection Agency, identify the ethylene oxide sterilization facilities in California that utilize oxidizing emissions control devices and conduct inspections of those facilities (including the Sterigenics Ontario facility) in terms of the findings of this report. Ensure prompt correction of all violations identified during these inspections.

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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Environmental Protection Agency (EPA)
2004-11-I-CA-16

Communicate the findings and recommendations of this report to the states that require EO backvent emissions treatment. Emphasize the need for facilities to evaluate current process controls and install appropriate safeguards, such as: - Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. - Post-ignition deflagration detection and damage control devices.

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.
 

Ethylene Oxide Sterilization Association (EOSA)
2004-11-I-CA-14

Coordinate with NIOSH to revise and reissue Appendix C of the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically, remove the portion of paragraph D that states, "[t]he accuracy, reliability, resolution, and availability of current ethylene oxide measurement devices is questionable."

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.
 

2004-11-I-CA-15

Conduct outreach to communicate the findings and recommendations of this report, and the contents of the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities, to your membership.

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.
 

Institute of Clean Air Companies (ICAC)
2004-11-I-CA-17

Communicate the findings and recommendations of this report to your membership.

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.
 

National Fire Protection Association (NFPA)
2004-11-I-CA-9

Review and revise NFPA 560, Standard for the Storage, Handling, and Use of Ethylene Oxide for Sterilization and Fumigation in terms of the findings of this report. Specifically:

  • Include references to the following:
    • NFPA 69, Standard on Explosion Prevention Systems. 
    • NFPA 86, Ovens and Furnaces. 
    • NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions in Industrial Ethylene Oxide Sterilization Facilities.

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.
 

2004-11-I-CA-10

Review and revise NFPA 560, Standard for the Storage, Handling, and Use of Ethylene Oxide for Sterilization and Fumigation in terms of the findings of this report. Specifically:

  • Include requirements for appropriate safeguards, such as:
    • Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. 
    • Post-ignition deflagration detection and damage control devices.

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.
 

National Institute for Occupational Safety and Health (NIOSH)
2004-11-I-CA-11

Revise and reissue the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically: - Include industry guidance materials on Process Hazard Analysis (PHA), such as those published by the Center for Chemical Process Safety (CCPS).

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.
 

2004-11-I-CA-12

Revise and reissue the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically: - Add references to NFPA 68 Guide for Venting of Deflagrations; NFPA 69 Standard on Explosion Prevention Systems; NFPA 86 Ovens and Furnaces; and NFPA 560 Standard for the Storage, Handling, and Use of Ethylene Oxide for Sterilization and Fumigation.

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.
 

2004-11-I-CA-13

Revise and reissue the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically: - Coordinate with the Ethylene Oxide Sterilization Association (EOSA) to remove the portion of paragraph D of Appendix C that states, ?[t]he accuracy, reliability, resolution, and availability of current ethylene oxide measurement devices is questionable.?

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.
 

Sterigenics International
2004-11-I-CA-1

Audit all Sterigenics ethylene oxide sterilization facilities using oxidizing emissions control devices. Ensure that audits assess the issues detailed below, under "Sterigenics International - Ontario Facility," and that necessary corrective measures are promptly implemented. Communicate results of these audits to your workforce.

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.
 

Sterigenics International - Ontario Facility
2004-11-I-CA-2

Review and revise the Process Hazard Analysis (PHA) program to ensure that: - Hazardous scenarios are identified, evaluated, and documented. - Lessons learned from past incidents are applied, where appropriate.

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.
 

2004-11-I-CA-3

Evaluate current process controls and install appropriate safeguards, such as: - Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. - Post-ignition deflagration detection and damage control devices.

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.
 

2004-11-I-CA-4

Ensure that all employees with passwords capable of modifying the sterilization cycle sequence have process experience and training that enables them to make safe process decisions. Training should emphasize flammability hazards and the need for gas washes when the chamber is empty of products to be sterilized.

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.
 

2004-11-I-CA-5

Ensure that the control room, and any other room where employees congregate in dangerous proximity to the sterilization area, is located and/or designed to protect workers from an explosion.

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.
 

2004-11-I-CA-6

Communicate the findings and recommendations of this report to all employees, including operators and maintenance staff.

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

Ethylene Oxide Explosion at Sterigenics
3/30/2006 5:00:00 AM
At a sterilization plant, bypassing a safety interlock has catastrophic results. read more

Download QuickTime Video

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