Accident: Hoeganaes Corporation Fatal Flash Fires
Location: Location: Gallatin, TN
Accident Occurred On: 01/31/2011 | Final Report Released On: 01/05/2012
Accident Type: Combustible Dust Explosion and Fire
Investigation Status: The CSB's investigation was approved by the board on December 16, 2011. The case study was released at a news conference in Nashville, TN, on January 5, 2012.
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.
Require all facilities covered by IFC Chapter 13 (2006 edition) to conform to NFPA standards for combustible dusts including NFPA 484.
Ensure that all industrial facilities in the City of Gallatin are inspected periodically against the International Fire Code. All facility inspections shall be documented.
Implement a program to ensure that fire inspectors and response personnel are trained to recognize and address combustible dust hazards.
Conduct periodic independent audits of the Hoeganaes Gallatin facility for compliance with the following NFPA standards, using knowledgeable experts, and implement all recommended corrective actions:
Develop training materials that address combustible dust and plant-specific metal dust hazards and train all employees and contractors. Require periodic (e.g., annual) refresher training for all employees and contractors.
Implement a preventive maintenance program and leak detection and leak mitigation procedures for all flammable gas piping and gas processing equipment.
Develop and implement a near-miss reporting and investigation policy that includes the following at a minimum:
Revise IFC Chapter 22 Combustible Dust Producing Operations; Section 2204.1 Standards, to require mandatory compliance and enforcement with the detailed requirements of the NFPA standards cited in the chapter, including NFPA 484.
Communicate the findings of this report to all your members, e.g. through a safety article in an upcoming monthly newsletter.
(Superseded by 2017-07-I-WI-R10 from the Didion Milling Co. investigation)
Ensure that the forthcoming OSHA Combustible Dust Standard includes coverage for combustible metal dusts including iron and steel powders.
Develop and publish a proposed combustible dust standard for general industry within one year of the approval of this case study.
Revise the Combustible Dust National Emphasis Program (NEP) to add industry codes for facilities that generate metal dusts (e.g., North American Industrial Classification System, NAICS, code 331111 Iron and Steel Mills, and other applicable codes not currently listed). Send notification letters to all facilities nationwide under these codes to inform them of the hazards of combustible metal dusts and NEP coverage.
Revise the state-adopted Dust National Emphasis Program (NEP) to add industry codes for facilities that generate metal dusts (e.g., North American Industrial Classification System, NAICS, code 331111 Iron and Steel Mills, and other applicable codes not currently listed). Send notification letters to all facilities statewide under these codes to inform them of the hazards of combustible metal dusts and NEP coverage.