Term Paper Assignment

Chemical Process Safety: Accident Case Study

A Case Study Report By:

Group 8
Ethan Mudd, Yin Tse, Malak Alabdulmuhsin, and Ayman Mohammed

Hoeganaes Corporation Fatal Flash Fires, Gallatin, TN

Presented to Dr. Douglas Ludlow of the Deparment

Chemical and Biochemical Engineering
Missouri University of Science and Technology

Submitted on: 10/04/2019

Abstract:
The Hoeganaes Corporation facility in Gallatin Tennessee is a major provider of iron
parts fashioned from the pressing and sintering of metal powder. Fine particles of iron metal dust
when dispersed in the air in the presence of an ignition source can combust and cause flash fires.
This was a somewhat normality at the Hoeganaes facility, though not usually resulting in serious
injury but still requiring the local fire department to respond to over thirty incidents of fires.
Until the January 31, 2011 incident none had resulted in serious injury or loss of life due to flash
fire injuries.
Incident one was the result of a dispersion of fine iron dust into the air that caught an
ignition source from the start-up and vibrations of the motor, engulfing both nearby employees,
causing both to be seriously injured one who would evenly succumb to injuries. The second
incident was the result of a worker performing repair work on a gas line for a furnace, the worker
decided to use a hammer to get the gas line in place, when the force of the hammer had dispersed
iron dust into the air it ignited burning the engineer resulting in 1st and 2nd degree burns. The
third incident was the consequence of a gas leak in a pipeline trench, highly flammable hydrogen
leaking from piping caused a powerful explosion from metal sparks. The force of the explosion
shook the building rafters that shed iron dust that would fall and ignite when coming into contact
with the fire.
An operation involving the handling of metal dust is required by the National Fire
Protection Association (NFPA) to perform at least one of two screen tests to evaluate the
combustibility of the metal dust. Through a prior insurance inspection Hoeganaes was made
aware of the combustibility properties of the iron metal dust two years before the first incident
occurred, rather than putting more rigorous safety procedures in place the company seemed to
ignore the warnings. Rather than instill proper engineering controls and housekeeping the only
change within the facility was an operation training program that was initiated by
Representatives from Hoeganaes as a response to the dust analysis, which did not ultimately help
mitigate the hazard. Still this training was not enough to train employees on how to avoid
flammable gas fires and explosions, or work procedures such as combustible gas monitoring.
The CSB, Chemical Safety Board, used combustible dust testing to analyze dust particles for
explosivity and combustible properties, the tests performed by the CSB involved a
combustibility demonstration, a Twenty-Liter Test, and a One-Meter Cubed Test, each showing
conclusive results for combustibility. Despite the clear hazard of iron dust particles in the facility
OSHA did not include the industrial classification code in its Combustible Dust Emphasis
Programs in either of the publications release up to 2008. Even with the City of Gallatin adopting
the International Fire Code for Combustible Dust, Hoeganaes was not forced into more
comprehensive and rigorous NFPA standards to prevent dust fires and explosions. The three
serious incidents of 2011 at the Gallatin Hoeganaes facility were the result of not only poor
engineering controls, administrative controls, and housekeeping, but a lack of overall knowledge
on what should be held standard to prevent fatal flash fires and explosions due to combustible
dust.
Introduction:
The Hoeganaes Corporation is a global engineering and manufacturing company that
produces metal powder and product solutions for automotive and industrial markets. Hoeganaes
has facilities throughout the United States, Germany, China and Romania that provide a large
amount of powdered metal to many consumers, mainly the automotive industry, that press and
sinter the powdered metal into small metal parts. The Hoeganaes Gallatin facility first became
operational in 1980 and had employed nearly two-hundred men and women. Since the
establishment of the Gallatin facility, Hoeganaes has increased production by over five-hundred
fifty percent, with the main product being a powder that was ninety-nine percent iron. Despite
many previous incidents that did not result in the loss of life the Hoeganaes company would fail
to instill more safe practice into their process.
In 2011 the Gallatin facility endured three accidents over the course of a short four-month
period that resulted in three employees severely injured and five fatalities. These accidents were
due to the dispersion of dust particles throughout the plant that would find an ignition source
resulting in dust explosions and flash fires. The combustibility of metal is not a newly
established hazard in the industry in general. The NFPA, National Fire Protection Association,
and publications from as early as the 1940s describing metal dusts, including iron, give detailed
information on the hazards and explosion protection methods for all types of dust are available to
help prevent incidents. Building construction and fire codes provide designing specifications,
maintenance recommendations, and proper equipment to specify proper methods for use to
minimalize or prevent incidents involving dust. This case study is an effort to evaluate the three
incidents that took place on January 31 March 29, and May 27 2011, in hopes to deliver a clear
description of the process, a concise timeline of events and results analysis for each event, and a
determination of the root of causes then a evaluation of the lessons learned from each incident.

Process description
According to the Hoeganaes facility in Gallatin, TN, to the Hoeganaes corporation of
Fatal Flash Fires the process and products are leading producer of atomized steel and iron
powders with plans and high energy in everything and care about their customers and provide a
higher product for their customers too. The engineered produces the ions powder and use for the
production of a new part. This actually starts with suspected bucket elevator motor and also
happened with a similar flash fire burn another worker in Hoeganaes both men are burned and
both of them are dead. So,In this process is going through the furnace.They inject water to
atomized the steel into fine metal powders after the high furnaces molten high of the scrap steel
and to make the iron more ductile, this powders mixed the materials to make structural parts, so
when the scrap became liquid carbon molted for both and the temperature is raised as well. The
heat actually tapped to be and also the heat subsequently proceeds to the furnace to refine the
heat and the temperature. The high velocity is teamed by liquid steel and also it is going to be in
high pressure. From the powder of water, this powder is conveyed to the subsequent processes,
after the powder is annealing operation the powder is screened and going to use for packing into
the containers for shipping. When they tasted the iron dust control program from the plant
sample they take the minimum of ignition energy to determined the sources for each of the
incidents.The CSB published in the general industry of metal dust including iron dust, and
hazard the samples is collected from the plant and did not effective at the process in Gallatin.
The dust can accumulate in flat overhead surf, so the Hoeganaes facility has difficult to reach
and clean the hazard dust as in Hoeganaes facilities as requires industrial for the safety standards
for companies to follow the international result as recommended.

Case Study Accident Timeline

Early morning at 5:00 am on January 31, 2011 Hoeganaes plant administrators associated
can elevator number 12 with being off-track and an upkeep specialist and a circuit tester were
called to review the hardware. During a CSB talk with, one of the laborers was inundated on fire,
very quickly after the engine was restarted. Therefore, two operators were burned and died
because of wrong observations. The story started, when the belt of bucket elevator went off-
track. The operators asked to restart the elevator motor which dispersed fine irons dust into the
air causing the fire.
On March 29 2011, an engineer burned with second-degree. He and other contractor were
working in replacing igniters on a band furnace. While they are trying to connect the natural gas
line, Hoeganaes engineer tossed large amounts of iron dust closely to the band furnace.
Immediately, the fire started and the engineer surrounded with the flame. The specialist was
wearing the Hoeganaes-assigned individual defensive hardware, that were appraised as fire safe
apparel (FRC). He was likewise wearing a FRC evaluated coat that gave additional protecting to
his upper middle from the blaze fire.
On May 27, 2011, three operators were died and two were injures. The story started when
operators, who usually works closely to the furnace, heard a noisy sound that considered as a gas
leak. They determined that gas came from trench, a workplace that has hydrogen, nitrogen, and
cooling water runoff pipes, and vent pipe for the furnaces. The furnace department called the
maintenance to fix the leak at 6:30 am. They assumed that the leak came from nitrogen pipe
which is nonflammable. So, they decided to take off the cover of trench with helping of carne.
During the lifting of trench cover, friction created sparks, followed by a powerful explosion. A
few days after the explosion, CSB agents watched a huge gap (roughly 3 x 7 inches) in a
consumed area of funneling that brought hydrogen and went through the channel. The
additionally announced in certain occurrences that flashlights were needed; one observer said
that even with a spotlight, he could see just 3-4 feet ahead because of broad residue and smoke.
The two mechanics close to the forklift were moved to a nearby emergency clinic where they
were treated for smoke inward breath and discharged presently. The other two mechanics and the
administrator who held on during the activity were moved to Vanderbilt Burn Center. The third
genuinely harmed worker died after seven weeks.

Ultimate Results
The first fatal incident at the Hoeganaes facility in Gallatin TN resulted in two employees
being severely burned over a large percentage of their body. Both were transported to the
Vanderbilt Burn Center in Nashville TN, and later succumbing to their injuries one passing two
days later and the other surviving four short months after the incident. This incident spurred an
investigation by the CSB, who observed, and test dust accumulated on machinery, rafters, and
the floor. Even after the findings of the combustibility tests shown all samples taken were
explosible there was no complete overhaul of the dust containment and housekeeping procedures
at the Gallatin facility.
The second incident that took place on March 29, 2011 two worked were involved, one
had escaped the area without injury and the other had been injured. The injured technician was
able to leave without server burns due to not only were personal protective equipment but also an
FRC rated jacket that protected his upper torso from the flash fire. After this incident the Gallatin
facility was visited by the local fire department, but the documented observation did not note any
combustible dust hazards only emergency egress and fire suppression.
After the May 27, 2011 incident the seen the lost of life to another two employees, one
other employee had been hospitalized for several years due to the severity of injuries, and two
employees injured but released same day from the hospital. After this incident the Gallatin
Hoeganaes facility would shut down for nearly a month to address a full plant safety review and
was forced to co-operate with Tennessee OSHA and the U.S. Chemical Safety Board to evaluate
the direct cause of the accident. After the first incident the CSB investigation noted holes in the
Hydrogen gas piping, but a full repair of the pipeline was never conducted. In total the Hydrogen
gas explosion and subsequent dust fires resulted in nearly thirty-seven million USD in damages
and cost of loss of workdays. In November 2011 Tennessee OSHA issued Hoeganaes Gallatin
Facility citations for the third incident. Fifteen OSHA PSM standard violations related to the
hydrogen gas system.
The Gallatin Fire Department (GFD) has reacted to 30 circumstances of different sorts in
the past 12 years at the Hoeganaes Corp. Including the January 31, March 29, and May 27
occurrences. In June 1999, the GFD reacted to a fire brought about by iron dust that touched off
in a baghouse. One individual endured smoke inward breath wounds. The Gallatin Fire
Department (GFD) has reacted to 30 circumstances of different sorts in the past 12 years at the
Hoeganaes Corp. Including the January 31, March 29, and May 27 occurrences. In June 1999,
the GFD reacted to a fire brought about by iron dust that touched off in a baghouse. One
individual endured smoke inward breath wounds. Every one of the 2011 incident, Hoeganaes
volunteer initially communicators thought about the injured. Hoeganaes volunteers take an
interest in yearly preparing that spreads first reaction, CPR, and medical aid. They are told to
care until GFD and EMS responders show up. Quickly following every occurrence, the
volunteers gave medical aid and solace to the harmed by applying water to cool the consumes
and covering the exploited people with a consume cover to keep them agreeable. EMS get in
shortly and transported the injured to emergency clinics.

Root of Causes of accident

The fatal accidents that occurred at Hoeganaes present an alarming disposition regarding
the management framework and safety culture for similar facilities that works with potentially
combustible materials. Industrial accidents typically involves with failure to adhere with the
fundamentals of inherently safer designs, recognition of accident precursor, and overall safety
culture. In the case of dust combustion at Hoeganaes, the root cause lies with risk normalization,
ineffective engineering and administrative control, and incompliance with industrial standard and
regulatory oversight.
Combustible dusts are solid materials that can cause potential fire when suspended in air.
Unlike typical fire incidents, dust fire requires the dispersion and confinement dust particulates
in addition to the needs of fuel, oxygen, and ignition source. Metal dust has been well-defined as
a potential combustible hazard by the industry. Organizations such the National Fire Protection
Association (NFPA) have provided lists of precaution codes for the prevention of dust related
incidents dating back to 1940s. NFPA code for dust operations, in particular, calls for the
avoidance of structural design with beams or ledges that allows dust accumulation and the
enforcement of good housekeeping procedures with well-maintained leakage-free equipment.
The Gallatin facility, built in 1980, did not designed in accordance with the building codes of
NFPA. Additionally, implementation of dust hazard mitigation was extremely limited due to
excessive leakage from existing equipment and unreliable dust collection system. Employees
have reported that baghouse filtration collectors were often down for maintenance, causing large
amounts of airborne combustible iron dust within the work environment. As result, there have
been over 30 reported minor incidents and numerous unreported near-miss incidents that have
occurred periodically prior to the events of May 27. Despite all this, Hoeganaes only implement
emergency first response training for volunteers and hazard recognition training for operators.
Employees were forced to tolerate the working hazards at the facility. As all events prior to the
three major incidents were limited to minor injuries, the risk of metal dust flash fires became
normalized and were part of the workers’ everyday life in the facility.
Risk normalization is not an acceptable behavior in industrial practice as it increases
workplace risk exposure. This, however, is not the only root cause for the three major incidents.
Detailed examination in engineering designs and administrative management is necessary to
understand the continual existence of hazardous conditions in the Gallatin facility. When
elimination and substitution of hazard could not be implemented, the hierarchy of control falls to
engineering controls and administrative controls. Engineering controls involves preventing
worker exposure by isolating and removing hazard at its source. Administrative controls works
by implementation of procedures to increase hazard awareness and maintenance. Engineering
control involves with proper installation and maintenance of dust collection systems, electrical
installations, pipping, and process management. In the case of Hoeganaes, failed implementation
of these control further accelerate worker exposure to potential dust fire. Installation and
maintaining of fugitive dust filtration system is one of the most effective method to dust fire
prevention. According to NFPA 484, installations of filtration system for combustible metal
needs to be outside of the facilities and all machine producing combustible hazard are requires
connection with the filtration system with minimal leakage. The baghouse filtration system,
located inside the Gallatin facility, had many of its conveyance equipment unenclosed, resulting
in insufficient dust containment due to lowered suction velocity. Combined with the frequent
unavailability of the dust collector due to maintenance, this leads to excessive accumulation of
explosive dust with the work facility. Under the NFPA 499, Class II rated electrical equipment is
required for any electrical installation located in a potentially combustible setting. To avoid
installation of Class II electrical equipment, appropriate combustible dust prevention must be
implemented. Furthermore, due to the existence of hydrogen piping trench under the floor, a
Division 2 designated area is required to isolate installed electrical services. The trench pipeline
system under the floor contains pipelines for hydrogen, nitrogen, furnace hot water drainage, and
furnace ventilation pipeline. The placement of hot water runoff pipes from the furnace resulted in
corrosion of other pipelines and subsequently the hydrogen gas leak. The hydrogen used comes
from an onsite generation with its own storage unit capacity exceeding 10,000 pounds of
hydrogen. Under the Process Safety Management Standard (PSM), hazardous chemical pipelines
exceeding 10,000 pounds in a single location requires a thorough development of procedures to
ensure mechanical integrity along with an appropriate emergency response plan for leakage. As
indicated by the May 27 incident, workers were not trained nor aware of the dangers posed by
potential hydrogen gas leak. Similarity the lack of housekeeping, hazard awareness training, and
continual ignorance of repeated incidents by administrative management led to the three tragedy
incidents in 2011.
While the fault of the incident falls entirely on the lack of engineer control and
administrative control within the facility, the inability to enforce a change in Hoeganaes’
behavior to these incidents also play an important role. The Gallatin facility remains operational
despite failing most standards and codes of practice implemented by organizations such as
NFPA, OSHA, and ICC. The Hoeganaes facility did not conform or volunteer to any suggestions
made. This was because most of these standards, such as NFPA 484, have a vague description as
to whether they are mandatory or voluntary. The Tennessee Fire Code does not enforce any
voluntary practice. Similarity, there was limited attempt in issuing violations or stop-work orders
to address the alarming hazardous work condition with the facility. Even though the Gallatin Fire
department has responded to over 30 incidents of various type with 1 major incident involving
hydrogen explosion and flash fire for the Hoeganaes facility prior to the 2011 incidents, the issue
of dust accumulation was never mention in any of the inspections conducted by the GFD and
TOSHA. This remains the case after the first two major incidents and two weeks prior the
incident of May 27. The only organization to mention the accumulation of iron dust was the
independent consultant insurance company, Allianz, due to an insurance audit in 2008. This
resulted in the Hoeganaes management conducting combustible dust test as recommend by the
insurance company, but no further substantial action was taken to prevent or mitigate
combustible dust hazard. Failure in implementing an accurate and concise enforcement rule
played a robust role in the Hoeganaes Gallatin facility’s deliberate attempt to ignore any
corrective action required for their process facility.
Lessons Learned
In summary, the repeated incidents occurred in the Hoeganaes facility is the result of
failure in multiple levels of the hierarchy of control, from engineering control to administrative
control to personal protective equipment that proved ineffective against combustible flash fire
and hydrogen explosion. Instead of ignoring existing issue, the accumulation of combustible dust
with its proximity to multiple ignition source could be prevented with proper housekeeping and
engineering controls. This is addressed by conforming to monitoring organization such as OSHA
Combustible Dust Standards to develop proper rules of conduct, hazard awareness training, and
emergency response along with other optional standards of practice. Incidents of any kind should
also be reported and proper investigation channel, such as hiring an external team, should be
executed to prevent any possible reoccurrence. Threshold monitoring system should also be
implemented when handling any dangerous chemicals in large quantities to prevent catastrophic
release to the environment or workplace. Pipelines in contact with external factors that would
otherwise place stress on ambient working conditions should be examined. All pipelines should
be monitored for leakage with proper mitigation controls in the case of leakage. Additionally,
regulating entities needs more jurisdiction and authority to enforce both mandatory and voluntary
compliance standards and practice when deemed necessary after facility inspection. Periodic
independent audits using knowledge experts for industrial facilities is also necessary for the
improvement of overall work condition.