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US Ink Fire
FINAL REPORT: Case Study
Location: East Rutherford , NJ
Accident Occurred On: 10/09/2012
Final Report Released On: 01/15/2015
Accident Type: Combustible Dust Explosion and Fire
Company Name: US Ink

statistics

Total # of Recommendations
9
Total # of Open Recommendations
9
Total # of Closed Recommendations
0
Total % of Open 100 vs. Closed 0

investigation information

Image
Accident Description
An explosion and fire injured 7 workers at the US Ink facility.
Investigation Status
The CSB issued its final report at a public meeting in East Rutherford, NJ, on January 15, 2015


 

Recommendations

New Jersey Department of Community Affairs
2013-01-I-NJ-3

Revise the exemption for “manufacturing, production, and process equipment” under the New Jersey Uniform Construction Code (N.J.A.C 5:23-2.2) to require that equipment involved in processing, handling, or conveying combustible dust comply with the design and operating requirements of the current edition of the International Building Code.

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.
 

2013-01-I-NJ-4

Develop and implement training for local code officials on the National Fire Protection Association (NFPA) standards referenced in the New Jersey adoption of the International Building Code (IBC) for occupancies with a high hazard classification (Group H); specifically, include training on equipment that handles combustible dust and the hazards involved.

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.
 

2013-01-I-NJ-5

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. Also require local enforcement agencies to evaluate the information to determine whether a construction permit is required.

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.
 

Occupational Safety and Health Administration (OSHA)
2006-1-H-1

Issue a standard designed to prevent combustible dust fires and explosions in general industry. Base the standard on current National Fire Protection Association (NFPA) dust explosion standards (including NFPA 654 and NFPA 484), and include at least - hazard assessment, - engineering controls, - housekeeping, - building design, - explosion protection, - operating procedures, and - worker training.

REITERATED!
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.
 

Download
2013-01-I-NJ-1

Add North American Industry Classification System (NAICS) Code 325910, Printing Ink Manufacturing, to the list of industries in Appendix D-1 or Appendix D-2 of Combustible Dust National Emphasis Program (NEP), Directive CPL 03-00-008.

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.
 

2013-01-I-NJ-2

Communicate with all OSHA Area Offices to encourage appropriate application of the following existing provisions of the Combustible Dust NEP, Directive CPL 03-00-008:

  • Paragraph IX, Section A2, indicates that area offices may add to their Combustible Dust NEP establishment lists those facilities in their jurisdictions with a Standard Industrial Classification System code, NAICS code, or both (other than those listed in Appendices D-1 and D-2 of the Combustible Dust NEP directive) if those facilities have a known pattern of combustible dust hazards.
  • Paragraph IX, Section B4, indicates that if a fatality or catastrophe investigation is performed at a facility because of a combustible dust deflagration or explosion, the inspector shall use the guidelines in Fatality/Catastrophe Investigation Procedures, Directive CPL 02-00-137, and in the Combustible Dust NEP, Directive CPL 03-00-008.
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.
 

US Ink/Sun Chemical Corporation
2013-01-I-NJ-6

At the US Ink East Rutherford facility, install automatic fire alarm systems consistent with NFPA 72 (the National Fire Alarm Code) in manufacturing areas (such as mixing) where heat generation could occur.

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.
 

2013-01-I-NJ-7

Revise the Capital Appropriations/Asset Request (CAR) form procedure for new installations and modifications to existing equipment to require at a minimum the following:

  • Process hazard analysis (PHA)
  • Management of change (MOC)
  • Review of engineering drawings for permits
  • Safety management of contractors
  • Training of plant operators based on applicable dust collection system guidelines and standards, including NFPA 91 and NFPA 654.
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.
 

2013-01-I-NJ-8

Develop and implement a management of organizational change protocol to allow for the transfer of knowledge and information to new personnel, at a minimum including initial or refresher training in the following:

  • Safety and health procedures
  • Lessons learned from previous incidents
  • Technical information for equipment
  • Routine plant operations.
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.
 

 
 

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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
1/15/2015
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 investigation by the U.S. Chemical Safety Board (CSB) has found.
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CSB to Hold Public Meeting in East Rutherford, NJ to Hear Findings from US Ink and Millard Investigations
1/9/2015
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