Investigations with findings related to emergency planning and response:


Incident Description


West Fertilizer Explosion and Fire

Incident Description:On April 17, 2013, 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. The CSB found that the West Volunteer Fire Department was not required to perform pre-incident planning for an ammonium nitrate-related emergency, nor were the volunteer firefighters required to attend training on responding to fires involving hazardous chemicals. As a result, the CSB made several safety recommendations to various stakeholders to better inform and train emergency responders on the hazards of FGAN and other hazardous chemicals.

Hoeganaes Corporation Fatal Flash Fires

Incident Description:On January 31, 2011; March 29, 2011; and May 27, 2011; 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. This case study examines multiple iron dust flash fires and a hydrogen explosion at the Hoeganaes facility in Gallatin, TN. The first iron dust flash fire incident killed two workers and the second injured an employee. The third incident, a hydrogen explosion and resulting iron dust flash fires, claimed three lives and injured two other workers. The Gallatin Fire Department (GFD) has responded to 30 incidents of various types over the previous 12 years at the Hoeganaes Corp., including the January 31, March 29, and May 27 incidents. In June 1999, the GFD responded to a fire caused by iron dust that ignited in a baghouse. One person suffered smoke inhalation injuries as a result of the incident.

CITGO Refinery Hydrofluoric Acid Release and Fire

Incident Description:On July 19, 2009, a hydrocarbon gas release occurred in the CITGO Corpus Christi East Refinery hydrogen fluoride (HF) alkylation unit at 1802 Nueces Bay Boulevard, Corpus Christi, Texas. The release ignited causing extensive damage; the ensuing fire burned for several days. The fire critically injured one CITGO employee. One other employee was treated for possible HF exposure during emergency response activities. The incident occurred when violent shaking in the process recycle piping broke two threaded connections, releasing highly flammable hydrocarbons. The shaking was caused by nearly complete flow blockage, which occurred due to the sudden failure of a control valve. During this incident, CITGO nearly exhausted its stored water supply for fire suppression and HF mitigation on the first day of the multi-day incident response. About 11.5 hours after the initial release, before the water supply was completely exhausted, the Refinery Terminal Fire Company began pumping salt water from the Corpus Christi ship channel into the CITGO fire water system using a barge equipped for firefighting. Multiple failures occurred during the salt water transfer, including multiple ruptures of the barge-to-shore transfer hoses and two water pump engine failures.

Bayer CropScience Pesticide Waste Tank Explosion

Incident Description:On August 28, 2008, a runaway chemical reaction occurred inside a 4,500 gallon pressure vessel known as a residue treater, causing the vessel to explode violently in the methomyl unit at the Bayer CropScience facility in Institute, West Virginia. Highly flammable solvent sprayed from the vessel and immediately ignited, causing an intense fire that burned for more than 4 hours. The fire was contained inside the Methomyl-Larvin insecticide unit by the Bayer CropScience fire brigade with mutual aid assistance from local volunteer and municipal fire departments. The incident occurred during the restart of the methomyl unit after an extended outage to upgrade the control system and replace the original residue treater vessel. Two company employees who had been dispatched by the control room personnel to investigate why the residue treater pressure was increasing were near the residue treater when it ruptured. One died from blunt force trauma and burn injuries sustained at the scene; the second died 41 days later at the Western Pennsylvania Burn Center in Pittsburgh, Pennsylvania. Six volunteer firefighters who assisted in the unit fire suppression activities and two contractors working at the facility were treated for possible toxic chemical exposure.


Little General Store Propane Explosion

Incident Description:On January 30, 2007, a propane explosion at the Little General Store in Ghent, West Virginia, killed two emergency responders (the Incident Commander (IC) and an Emergency Medical Technician (EMT)) and two propane service technicians, and injured six others that included the second EMT. The explosion leveled the store, destroyed a responding ambulance, and damaged other nearby vehicles.

EQ Hazardous Waste Plant Explosions and Fire

Incident Description:On October 5, 2006, a citizen driving past the EQ facility called 911 to report a haze with a “strong chlorine smell.” The Apex 911 center dispatched emergency personnel to investigate. Responding Apex Fire Department personnel discovered a chemical cloud coming from one of several businesses on Investment Boulevard. The Apex Fire Chief, acting as the Incident Commander (IC), sent two firefighter reconnaissance teams in personal protective equipment to investigate the source of the cloud. Firefighters located a small “sofa-size” fire in one of the hazardous waste bays at the EQ facility. Within minutes, the fire spread to the flammable liquid storage area, causing 55-gallon drums of flammable hazardous waste to explode and sending fireballs hundreds of feet into the air. The hazardous waste building ultimately collapsed (cover photograph). During the incident, about 30 people (including 13 first responders) sought medical attention at local hospitals for respiratory distress and nausea. Some were treated; none was admitted.

Universal Form Clamp Co. Explosion and Fire

Incident Description:On June 14, 2006, an operator was mixing and heating a flammable mixture of heptane and mineral spirits in a 2,200-gallon open top tank equipped with steam coils. The finished product, “Super Clean and Tilt,” is a proprietary mixture, which is applied to cured concrete surfaces to prevent bonding with wet concrete. As the operator was adding an ingredient to the batch, he observed a “dense fog” accumulating on the floor below the tank. He immediately notified a senior operator who helped him shut down the operation. They both exited the building and advised workers in adjoining areas to leave. As the vapor cloud spread throughout the mixing area and surrounding workspaces, other employees exited the building. Within about 10 minutes after the operator first observed the vapor cloud, most employees who were working in the area had evacuated. A contracted delivery driver passed some of these employees as he walked into the building and into the spreading vapor cloud. The cloud ignited within seconds of him entering. The driver died several days later from the burns he received. The pressure created by the ignition blew the doors open to an adjacent area, injuring a temporary employee. This employee suffered second-degree burns and was hospitalized for three days. The Bellwood Fire Department battled a fire confined to a bagged resin storage area for about three and one-half hours. The fire and pressure from the initial ignition produced moderate damage to the structure and interrupted operations for nearly one month. UFC suspended the flammable liquid mixing operation indefinitely.

MFG Chemical Inc. Toxic Gas Release

Incident Description:On April 12, 2004, a runaway chemical reaction during the production of triallyl cyanurate at MFG Chemical, Inc.  (MFG) in Dalton, Georgia, released highly toxic and flammable allyl alcohol and toxic allyl chloride into the nearby community, forcing the evacuation of more than 200 families. One worker received chemical burns and 154 people, including 15 police and ambulance personnel, required decontamination and treatment for chemical exposure. The applicable emergency response plans lacked sufficient shelter-in-place and evacuation information; and the emergency response HAZMAT teams did not have sufficient personal protective or air monitoring equipment.

Honeywell Chemical Incidents

Incident Description:On July 20, 2003, there was a release of chlorine gas from the Honeywell refrigerant manufacturing plant in Baton Rouge, Louisiana. The accident resulted in the hospitalization of four plant workers and required residents within a half-mile radius to shelter in their homes. On July 29, 2003, a worker was fatally injured by exposure to antimony pentachloride when a gas cylinder released its contents to the atmosphere. On August 13, 2003, two plant workers were exposed to hydrofluoric acid, and one was hospitalized. There was a significant delay between the Honeywell report of an incident and the Baton Rouge Fire Department activation of the shelter-in-place alert.

DPC Enterprises Glendale Chlorine Release

Incident Description:On November 17, 2003, there was a release of chlorine gas from the DPC Enterprises chlorine repackaging facility in Glendale, Arizona, near Phoenix. Fourteen people, including ten police officers, required treatment for chlorine exposure. The release occurred when chlorine vapors from a rail car unloading operation escaped from a system designed to recapture the material, known as a scrubber. Owing to the exhaustion of absorbent chemicals in the scrubber, chlorine gas was released. None of the police officers who entered the potentially hazardous area wore respiratory protection.

Georgia-Pacific Corp. Hydrogen Sulfide Poisoning

Incident Description:On January 16, 2002, highly toxic hydrogen sulfide gas leaked from a sewer manway at the Georgia-Pacific Naheola mill in Pennington, Alabama. Several people working near the manway were exposed to the gas. Two contractors from Burkes Construction, Inc., were killed. Eight people were injured–seven employees of Burkes Construction and one employee of Davison Transport, Inc. Choctaw County paramedics who transported the victims to hospitals reported a strong odor in their ambulance bays and exhibited symptoms of hydrogen sulfide exposure.


DPC Enterprises Festus Chlorine Release

Incident Description:On August 14, 2002, a chlorine transfer hose ruptured during a rail car unloading operation at the DPC Enterprises chlorine repackaging facility near Festus, Missouri. The hose rupture ultimately led to the release of 48,000 pounds of chlorine, causing three workers and 63 residents to seek medical treatment. The CSB found that DPC lacked an effective testing and inspection program for its chlorine emergency shutdown system. Emergency shutdown valves failed to close properly once the chlorine leak had begun, greatly extending the duration and severity of the release. Investigators concluded that the valves were inoperable due to internal system corrosion, in turn caused by inadvertent introduction of moisture into the chlorine system. DPC's testing and inspection program was inadequate to uncover the faulty condition of the valves before the accident occurred. The emergency response plan was inadequate in several areas including community notification, access to equipment, etc.

First Chemical Corp. Reactive Chemical Explosion

Incident Description: On October 13, 2002, a violent explosion occurred in a chemical distillation tower at First Chemical Corporation in Pascagoula, Mississippi, sending heavy debris over a wide area. Three workers in the control room were injured by shattered glass. One nitrotoluene storage tank at the site was punctured by explosion debris, igniting a fire that burned for several hours. The community notification system did not adequately warn residents that an incident was ongoing, explain how to shelter-in-place, or let them know when the emergency had subsided.

Herrig Brothers Farm Propane Tank Explosion

Incident Description:On April 9, 1998, an 18,000-gallon propane tank exploded at the Herrig Brothers farm in Albert City, Iowa. The explosion killed two volunteer firefighters and injured seven other emergency response personnel. Several buildings were also damaged by the blast.


Last updated September 06, 2017