Term Paper Assignment

Chemical Process Safety: Accident Case Study

A Case Study Report By:

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.

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.