Rockford, Illinois, November 14, 2013—The U.S. Chemical Safety Board (CSB) today released “Falling through the Cracks,” a safety video on the 2009 explosion at NDK Crystal in Belvidere, Illinois, which fatally injured a truck driver at a nearby gas station. The video contains an animation which depicts the stress corrosion cracking that accumulated over time in the walls of the vessel where synthetic quartz crystals were manufactured under extremely high pressures and temperatures.
LINK TO VIDEO
The video was released simultaneously with the CSB investigation report on the accident, set for consideration at a public meeting of the board in Rockford, Illinois, today, several miles from the NDK facility.
CSB Chairperson Rafael Moure-Eraso said, “The video dramatically describes the important findings of the CSB investigation – pressure vessels did not meet code requirements, but were granted an exemption; internal corrosion inspections were recommended but never performed; and finally a specific warning was made to the company by its insurer. But at every level, the risk of catastrophic vessel failure was overlooked and public safety, literally and figuratively, fell through the cracks.”
The video details CSB key findings and recommendations made by the board to prevent future accidents at NDK and to improve national pressure vessel codes and standards.
The accident occurred December 7, 2009, with a violent rupture in the Number 2 vessel. A combination of animation and surveillance video shows how one piece of steel from the building was blown 650 feet, striking a truck driver who was walking back to his vehicle. Another piece – a vessel fragment weighing over 8,000 pounds -- tore through a wall at the facility, skipped across a neighboring parking lot and struck the wall of an automotive supply company where 70 people were working; but only one was injured.
The video displays text of a direct warning by a third-party safety auditor called in by the NDK insurance carrier following an uncontrolled leak of hot, caustic material in January 2007 from the lid of another similar pressure vessel. The consultant concluded the accident resulted from the vessel’s improper design, fabrication and material selection, determined four vessels were experiencing stress corrosion cracking, and advised against returning any of the facility’s eight vessels into service, saying “far more catastrophic scenarios are possible,” specifically naming danger of public death or injury at the gas station where the truck driver would be killed in 2009. But NDK never established an internal vessel inspection program and did not perform testing on the vessels before returning them to service.
CSB lead investigator Johnnie Banks said, “The video shows how cracking on and near the inner diameter of the vessel fragment reduced the vessel material toughness, which eventually led to large flaws resulting in the catastrophic failure.” CSB investigator Lucy Sciallo-Tyler added, “We hope operators in the chemical industry take away the clear message that warnings and near misses must be acted on immediately to prevent major accidents.”
CSB Safety Videos typically feature detailed animation sequences to depict the chemical processes and sequence of events that led to explosions, fires and releases causing injuries, deaths, damage and destruction of production facilities. They have received accolades from safety professionals around the world, who have told the CSB they use the videos in training, seminars, board presentations and other venues as object lessons in the consequences of inadequate process safety management.
The videos have received numerous awards, the latest in November 2012 from TIVA, an organization of Washington, DC –based video professionals: “Experimenting with Danger,” on an academic laboratory explosion in Lubbock, Texas and “Hot Work: Hidden Hazards” received bronze Peer awards, while “Iron in the Fire” received a silver Peer award.
CSB videos may be streamed and downloaded at www.CSB.gov from the CSB media room. They are also available on www.YouTube.com/uscsb.
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 Communications Manager Hillary Cohen, cell 202-446-8094 or Sandy Gilmour, Public Affairs, cell 202-251-5496.