Open hole to the interior cavity on rollers. Photo: Chemical Safety Board
Washington — Chemical facilities should establish safety management systems “even in the absence of regulatory requirements” and communicate lessons from past incidents to help keep workers safe, the Chemical Safety Board says.
CSB recently issued a final report on a fatal explosion and eruption in May 2024 at the Techniques Surfaces USA facility in Chattanooga, TN.
Agency investigators found that an explosion stemming from a liquid nitriding process resulted as workers processed rollers submerged in molten salt baths. One roller remained plugged with salt. After being rinsed in hot water to remove residual salt, the rollers were reinserted into the 800° F salt bath to melt salt from the plugged roller.
However, pressure and steam accumulated in the plugged roller, resulting in an eruption that killed one worker and injured three others.
CSB determined that the facility lacked an “adequate process safety management system” when the incident occurred, as well as proper training and hazard analyses. Additionally, the agency found that similar incidents occurred at facilities operated by TS USA’s parent company but takeaways from resulting risk assessments weren’t shared.
Had this happened, CSB asserts, “TS USA could have ensured that the necessary safeguards were in place when processing parts through the nitriding line” and the incident “likely could have been prevented.”
Other lessons:
- Incorporate elimination of hazards or inherently safer design concepts – such as simplification – into hazard analyses to ensure effective and reliable controls are in place to protect workers from process hazards.
- Maintain an incident investigation program that generates formal reports, performs casual analysis and reviews corrective actions. Communicate and translate investigation findings throughout the worksite and to other company facilities.
- Ensure critical safety information is communicated to all employers and that safety knowledge is managed and institutionalized throughout the company.
- Assess critical safety tasks to ensure policies and procedures are in place and organizational expectations are being followed at all levels.
“This terrible incident underscores how critically important it is for facilities like TS USA to have a comprehensive and effective safety management system in place,” CSB Chair Steve Owens said in a press release. “The absence of strong process safety protocols – and the failure to apply lessons from past similar events – put TS USA’s workers at serious risk, with one of them tragically being killed.”
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Original article published by Safety+Health an NSC publication