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West Fertilizer Explosion and Fire
FINAL REPORT: West Fertilizer Final Investigation Report
Location: West, TX
Accident Occurred On: 04/17/2013
Final Report Released On: 01/28/2016
Accident Type: Chemical Distribution - Fire and Explosion

statistics

Total # of Recommendations
19
Total # of Open Recommendations
19
Total # of Closed Recommendations
0
Total % of Open 100 vs. Closed 0

investigation information

Image
Accident Description
A massive explosion at a fertilizer storage and distribution facility fatally injured twelve volunteer firefighters, two members of the public and caused hundreds of injuries.
Investigation Status
The CSB's investigation was approved by a unanimous board vote at a public meeting in Waco, TX, on January 28, 2016.


 

Recommendations

Department of Homeland Security, Federal Emergency Management Agency (FEMA)
2013-02-I-TX-7

Through a new or existing program and in conjunction with training partners, create and implement a competitive funding mechanism to provide training to regional, state, and local career and volunteer fire departments on how to respond to fire and explosion incidents at facilities that store fertilizer grade ammonium nitrate (FGAN).  Continue to use available funding to ensure training effectiveness.

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.
 

2013-02-I-TX-8

During the proposal review process for the program, ensure that the FGAN training includes multiple delivery methods to enable a broad reach.  Training should allow for instructor-led, web-based, and train-the-trainer courses; initial orientation; and refresher training.  Training also should accommodate both resident and mobile capabilities to facilitate flexible delivery.
Objectives of the selected training course should address the following:
a. Previous FGAN fire and explosion incidents, incorporating lessons learned

b. Hazards posed by other materials and chemicals stored near FGAN, including FGAN incompatibility with those materials and chemicals

c. Pre-incident planning for fires involving FGAN d. On-scene emergency response and decision-making requirements for FGAN fires, including risk assessment, scene size-up, and situational awareness

e. National Incident Management System and Incident Command System.

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.
 

2013-02-I-TX-9

Assist training partners to develop and provide continual oversight for an FGAN training program.  In addition, evaluate the training curriculum to confirm that it adequately meets course objectives as well as the details of recommendation 2013-02-I-TX R8.

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.
 

2013-02-I-TX-10

Develop an outreach program that notifies regional, state, and local fire departments about available FGAN training opportunities.  The program should include the following:

a. Guidance for fire departments on how to identify FGAN hazards within their communities by engaging State Emergency Response Commissions and Local Emergency Planning Committees

b. Details on how to obtain FGAN training by submitting a proposal in response to the funding opportunity

c. Information on training partners and programs that provide FGAN training.

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.
 

El Dorado Chemical Company
2013-02-I-TX-19

For all distributors and bulk retail sites (i.e., customers) that receive fertilizer grade ammonium nitrate (FGAN) manufactured by El Dorado Chemical Company (EDC) for storage, shipment, and sale:

a. Encourage customers to conduct internal monitoring and auditing (in accordance with recent industry standards and guidelines) in locations where FGAN will be stored or used.  Communicate that such internal monitoring and auditing may be conducted through established product safety programs, including ResponsibleAg.

b. Develop a process to establish mutual product stewardship expectations for the downstream chain of customers.  Communicate expectations to existing customers, and to new customers before their first shipment of FGAN.  Include the following components:

i. For all FGAN sold to distributors, encourage distributors to provide Safety Data Sheets and FGAN safety guidance to their customers and bulk retail sites to which FGAN is sold or shipped

ii. For all EDC bulk retailers and non-EDC bulk retailers that store and sell FGAN, encourage bulk retailers to address, such as through certification checklists, the following:

• Written procedures for the safe handling of FGAN, including employee training

• Emergency response plans to be sent to Local Emergency Planning Committees and local fire departments

• Tier II Chemical Inventory Report submissions.

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.
 

Environmental Protection Agency (EPA)
2013-02-I-TX-1

Develop a guidance document on Emergency Planning and Community Right-to-Know Act (EPCRA) requirements that is issued annually to State Emergency Response Commissions(SERCs) and Local Emergency Planning Committees (LEPCs) and ensure that the guidance focuses on the following:

a. Explains which chemicals are exempt and which must be reported.

b. Describes how emergency responders should use Tier I and Tier II inventory reports and Safety Data Sheets, such as in safety training, practice drills, and for emergency planning.

c. Includes comprehensive LEPC planning requirements, with an emphasis on annual training exercises and drills for local emergency response agencies.

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.
 

2013-02-I-TX-2

Develop a general guidance document on the agricultural exemption under EPCRA Section311(e)(5) and its associated regulation, 40 CFR 370.13(c)(3), to clarify that fertilizer facilities that store or blend fertilizer are covered under EPCRA.  Communicate to the fertilizer industry publication of this guidance document as well as the intention of Section 311(e)(5).

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.
 

2013-02-I-TX-3

Revise the Risk Management Program rule to include fertilizer grade ammonium nitrate (FGAN) at an appropriate threshold quantity on the List of Regulated Substances.

a. Ensure that the calculation for the offsite consequence analysis considers the unique explosive characteristics of FGAN explosions to determine the endpoint for explosive effects and overpressure levels.  Examples of such analyses include that adopted by the 2014 Fire Protection Research Foundation report, “Separation Distances in NFPA Codes and Standards,” Great Britain’s Health and Safety Executive, and other technical guidance.

b. Develop Risk Management Program rule guidance document(s) for regulated FGAN facilities.

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)
2013-02-I-TX-6

In a subsequent edition of the International Fire Code, develop a chapter or a separate section under Chapter 50 (“Hazardous Materials”) or Chapter 63 (“Oxidizers, Oxidizing Gases and Oxidizing Cryogenic Fluids”) that includes the following requirements for the storage and handling of ammonium nitrate (AN):

a. Require automatic fire detection and suppression systems in existing buildings constructed of combustible materials

b. Provide ventilation requirements in accordance with the International Mechanical Code to prevent the accumulation of off-gases produced during AN decomposition

c. Provide smoke and heat vents to remove heat from AN during fire situations

d. Establish minimum safe separation distances between AN and combustible materials to avoid contamination in the event of fire.

e. Prohibit the use of combustible materials of construction.

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)
2013-02-I-TX-4

Develop and issue a Regional Emphasis Program for Section (i) of the Explosives and Blasting Agent standard, 29 CFR 1910.109(i), in appropriate regions (such as Regions IV, VI, and VII) where fertilizer grade ammonium nitrate (FGAN) facilities similar to the West Fertilizer Company facility are prevalent.  Establish a minimum number of emphasis program inspections per region for each fiscal year.  Work with regional offices to communicate information about the emphasis program to potential inspection recipients. 

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.
 

2013-02-I-TX-5

Implement one of the following two regulatory changes, either option (a) or (b) below, to address

FGAN hazards:
a. Add FGAN to the OSHA Process Safety Management (PSM) standard List of Highly Hazardous Chemicals, Toxics and Reactives in 29 CFR 1910.119, Appendix A, and establish an appropriate threshold quantity.  Identify National Fire Protection Association (NFPA) 400 as a source of Recognized and Generally Accepted Good Engineering Practices (RAGAGEP) for PSM-covered FGAN equipment and processes.
b. Revise the OSHA Explosives and Blasting Agents standard, 29 CFR 1910.109, to ensure that the title, scope, or both make(s) clear that the standard applies to facilities that store bulk quantities of FGAN.  Revise 1910.109(i), “Storage of Ammonium Nitrate,” to include requirements similar to those in NFPA 400, Hazardous Materials Code (2016

Edition), Chapter 11.  Ensure the following elements are considered:
i. For new construction, prohibit combustible materials of construction for FGAN facilities and FGAN bins. For existing facilities, establish a phase-in requirement for the replacement of wooden bins with bins made of noncombustible materials of construction within a reasonable time period (e.g., 3 to 5 years from the date standard revisions are enacted), based on feedback from the fertilizer industry.

ii. Require automatic fire sprinkler systems and fire detection systems for indoor FGAN storage areas.

iii. Define adequate ventilation for FGAN for indoor storage areas.

iv. Require all FGAN storage areas to be isolated from the storage of combustible, flammable, and other contaminating materials.

v. Establish separation distances between FGAN storage areas and other hazardous chemicals, processes, and facility boundaries.

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.
 

State Firefighters' and Fire Marshals' Association of Texas
2013-02-I-TX-13

Develop a fertilizer grade ammonium nitrate (FGAN) training certification program for fire departments that either have FGAN facilities in their jurisdictions or respond as mutual aid to other jurisdictions with FGAN facilities.  The certification program should include multiple delivery methods to enable a broad reach.  The certification program should allow for instructor-led, web-based, and train-the-trainer courses; initial orientation; and refresher training.  The training also should accommodate both resident and mobile capabilities to facilitate flexibility in delivery.

The criteria for the certification program should address the following:

a. Previous FGAN fire and explosion incidents, incorporating lessons learned

b. Hazards posed by other materials and chemicals stored near FGAN, including FGAN incompatibility with those materials and chemicals

c. Pre-incident planning for fires involving FGAN

d. On-scene emergency response and decision-making requirements for FGAN fires, including risk assessment, scene size-up, and situational awareness

e. National Incident Management System and Incident Command System.

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.
 

2013-02-I-TX-14

Develop an outreach component for the training certification program that notifies regional, state, and local fire departments with FGAN facilities in their jurisdictions about the training certification opportunities available for FGAN.  Ensure that the following items are included in the development of this program:

a. Guidance for fire departments on how to identify FGAN hazards within their communities by engaging State Emergency Response Commissions and Local Emergency Planning Committees

b. Encouragement for members in jurisdictions with FGAN facilities to become certified in FGAN training

c. Information on training partners and programs that provide FGAN training.

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.
 

Texas A&M Engineering Extension Services
2013-02-I-TX-15

Develop and administer a hazardous materials training module for career and volunteer fire departments that addresses fertilizer grade ammonium nitrate (FGAN) and other hazardous materials or chemicals that could pose new specialized hazards.  Ensure that the training includes multiple delivery methods to enable a broad reach.  The training should allow for instructor-led, web-based, and train-the-trainer courses; initial orientation; and refresher training.  The training also should accommodate both resident and mobile capabilities to facilitate flexibility in delivery.

Objectives of the training course should address the following:

a. How to respond to industrial fires involving FGAN and other hazardous materials or chemicals that could pose new specialized hazards to responding firefighters

b. Previous FGAN fire and explosion incidents, incorporating lessons learned

c. Hazards posed by other materials and chemicals stored near the FGAN, including FGAN incompatibility with those materials and chemicals

d. Pre-incident planning for fires involving FGAN and other hazardous materials or chemicals that could pose new specialized hazards to responding firefighters

e. On-scene emergency response and decision-making requirements for FGAN fires, including risk assessment, scene size-up, and situational awareness

f. National Incident Management System and Incident Command System.

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.
 

2013-02-I-TX-16

Develop an outreach program that notifies state, regional, and local fire departments about available FGAN training opportunities.  The program should include the following elements:

a. Guidance for fire departments on how to identify FGAN and other recognized hazards associated with other hazardous materials or chemicals within their communities by engaging with State Emergency Response Commissions and Local Emergency Planning Committees

b. Promotion of use of the hazardous materials training module with TEEX training partners.

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.
 

Texas Commission on Fire Protection
2013-02-I-TX-11

Develop minimum standards for course curricula to include hazard awareness of fertilizer grade ammonium nitrate (FGAN) for those fire departments that either have FGAN facilities in their jurisdictions or respond as mutual aid to other jurisdictions with FGAN facilities.  In addition, develop a training program specific to FGAN.

Objectives of the program’s training course should address the following:

a. Previous FGAN fire and explosion incidents, incorporating lessons learned

b. Hazards posed by other materials and chemicals stored near FGAN, including FGAN incompatibility with those materials and chemicals

c. Pre-incident planning for fires involving FGAN

d. On-scene emergency response and decision-making requirements for FGAN fires, including risk assessment, scene size-up, and situational awareness

e. National Incident Management System and Incident Command System.

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.
 

2013-02-I-TX-12

Implement outreach to regional, state, and local fire departments that either have FGAN facilities in their jurisdictions or respond as mutual aid to jurisdictions with FGAN facilities, informing them about the new FGAN training certification requirements and opportunities to receive training.  Include the following in the outreach:

a. Guidance for fire departments on how to identify FGAN hazards within their communities by engaging  State Emergency Response Commissions and Local Emergency Planning Committees

b. Encouragement for fire departments in jurisdictions with FGAN facilities to become certified in FGAN training.

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.
 

Texas Department of Insurance
2013-02-I-TX-17

For companies that provide insurance to agricultural facilities storing bulk fertilizer grade ammonium nitrate (FGAN) in Texas, including surplus lines insurers and Texas-registered risk retention groups, develop and issue guidance to assist in underwriting risk and conducting annual loss control surveys.  Guidance should include the following:

a. Combustible materials of construction for facilities and bins storing FGAN

b. Storage of combustible materials near FGAN piles

c. Adequate ventilation for indoor FGAN storage areas

d. Automatic sprinklers and smoke detection systems for indoor FGAN storage areas

e. Separation distances between FGAN and other hazardous materials onsite

f. Potential for offsite consequences from a fire or explosion, including the proximity of FGAN facilities to nearby residences, schools, hospitals, and other community structures.

Provide references in the guidance document to existing materials from the following sources or to other equivalent guidance:

a. National Fire Protection Association (NFPA), NFPA 400, Hazardous Materials Code, 2016 Edition, Chapter 11, “Ammonium Nitrate”

b. FM Global, “Property Loss Prevention Data Sheet 7-89”

c. U.S. Environmental Protection Agency, Occupational Safety and Health Administration, and Bureau of Alcohol, Tobacco, Firearms and Explosives; “Chemical Advisory: Safe Storage, Handling, and Management of Solid Ammonium Nitrate Prills”

d. TDI, “Best Practices for the Storage of Ammonium Nitrate”

e. National Fire Protection Research Foundation, “Separation Distances and NFPA Codes and Standards.”

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.
 

West Volunteer Fire Department
2013-02-I-TX-18

Develop standard operating procedures for pre-incident planning for facilities that store or handle hazardous materials such as fertilizer grade ammonium nitrate (FGAN).

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.
 

 
 

Related Video

Dangerously Close: Explosion in West, Texas
1/29/2016 3:41:00 PM
CSB Safety Video on the April 17, 2013, fire and explosion at the West Fertilizer Company in West, Texas, which resulted in 15 fatalities, 260 injuries, and widespread community damage. read more

Download QuickTime Video
CSB Video Documenting the Blast Damage in West, Texas CSB Video Documenting the Blast Damage in West, Texas
5/10/2013 4:22:00 PM
On May 3, 2013, U.S. Chemical Safety Board investigator Jerad Denton took a film crew into West, Texas, to document the level of community damage from the fertilizer explosion that killed 14 and injured about 200 others. This 3-minute video shows the devastation. read more

Download QuickTime Video

Related News

GOPR0098
CSB board approves the West Fertilizer Company report and recommendations with a unanimous vote
1/29/2016
The final report and recommendations are based on the investigation by the CSB of the April 17, 2013, fire and explosion that killed 15 people and injured 260 others in West, Texas.
read more
Screengrab4
Chemical Safety Board Releases New Safety Video, "Dangerously Close: Explosion in West, Texas,” Detailing Report Findings and Recommendations on 2013 Fatal West Fertilizer Company Explosion and Fire
1/29/2016
January 29, 2016, Washington, DC – Today the U.S. Chemical Safety Board (CSB) released a safety video into the fatal April 17, 2013, fire and explosion at the West Fertilizer Company in West, Texas, which resulted in 15 fatalities, 260 injuries, and widespread community damage.
read more
Screengrab4
Download the CSB's West Fertilizer Company Animation
1/28/2016
Click to download the animation of the April 17, 2013, fire and explosion at the West Fertilizer Company
read more
 
 
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