Root Cause Analysis Report

2 Fatalities - Dust Explosion

Problem Statement
Report Number SAF-No. 2011-4-I-TN RCA Owner Jon Boisoneau
Report Date 1/10/2012 RCA Facilitator Maryanne Schull

Focal Point: 2 Fatalities

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When
Start Date: 1/31/2011 End Date: 1/31/2011
Start Time: 5:00am End Time: 5:00am

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Unique Timing After requesting that a motor be restarted
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Where
Component Bucket elevator #12 and motor
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Iron dust - 45 to 150 microns

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Actual Impact
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Safety 2 Fatalities $0.00

Revenue Unknown, but major $0.00
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Cost Unknown, but major $0.00

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Publicity: Severe negative impact $0.00

Employee Confidence: Severe negative $0.00
impact
Frequency Note Multiple flash fires occurred in the history of the plant, but none were fatal until
1/31/2011

Potential Impact
Safety Mulitple fatalities and injuries $0.00

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 Root Cause Analysis Report
2 Fatalities - Dust Explosion

Report Summaries
Cause and Effect Summary

DISCLAIMER:
The purpose of this example RCA is to provide a learning aid to Sologic students and others interested in root cause
analysis. Information contained in Sologic published examples is from publicly available sources, such as newspaper
and magazine articles, published governmental reports, academic papers, or occasionally from first-hand knowledge
of the event. Sologic has not investigated any event published at sologic.com professionally. If you have questions,

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comments, or concerns please send us an email at info@sologic.com

On January 31, 2011 at around 5:00AM, the [company] experienced an incident that led to two fatalities. Two
employees were severely burned in an iron dust fire. The employees were wearing fire protective clothing, however

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this was not adequate protection due to the temperature of the fire, the contact time with the fire, and the proximity of
the employees to the fire. The two employees had been sent to repair a belt conveyor motor that had tripped.
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Upon examination, the employees did not find an obvious problem. One employee radioed the control room to
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attempt to restart the motor. This triggered an iron dust fire that immediately engulfed the two workers. When the
motor was restarted, it caused vibration in the surrounding equipment. This vibration mobilized into the air a large
amount of iron dust that had settled on the equipment and surrounding structures.
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This dust encountered an ignition source - likely exposed wiring for the motor - and immediately ignited. It is unknown
why the wiring had been left exposed. The team also discovered that the motor was not grounded properly, which
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could have contributed to the ignition.

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There are tons of iron dust throughout the entire facility. The facility was not designed according to dust management
best practices and therefore has many flat surfaces that can gather dust in areas where cleaning is difficult. The iron
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dust comes primarily from muliple places in the dust handling system that are not completely sealed. Also, dust comes
from open conveyor systems. The dust collection system is down frequently due to mechanical failures. There are
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regulatory gaps and loopholes which prevent oversight of this type of production facility.

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 Root Cause Analysis Report
2 Fatalities - Dust Explosion

Solutions
SO-0001 Solution Identify and seal leaks in dust handling system.
Cause(s) Dust handling system not completely sealed
Note Inspect the plant for contributors to airborne dust through seal leaks. Rank
them, and work on eliminating the largest contributors.
Assigned Criteria Passed

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Due Status Identified
Term medium Cost $0.00

SO-0002 Solution Replace with closed conveyers, or modify existing so they are enclosed

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Cause(s) Open conveyers
Note No notes ic
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Assigned Criteria Passed
Due Status Identified
Term medium Cost $0.00
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SO-0003 Solution Implement housekeeping practices and standards

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Cause(s) Accumulated iron dust not cleaned up

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Note Housekeeping should become much easier once the sources of dust are
identified and eliminated.
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Assigned Criteria Passed

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Due Status Identified

Term short Cost $0.00

SO-0004 Solution Conduct dyanamic analysis into dust collection system outages
Cause(s) Dust collection system frequently down
Note The dust collection system has reliability problems. Complete a reliabilty
assessment of the dust collection system and develop a plan to reduce the
number and severity of outages.
Assigned Criteria Passed
Due Status Identified
Term short Cost $0.00

SO-0005 Solution Develop a plan to improve the dust accumulation properties of the plant design

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 Cause(s) Facility design susceptible to dust accumulation

Note Utilize best practices for making a facility resilient to dust accumulation.
Assigned Criteria Passed
Due Status Identified
Term medium Cost $0.00

SO-0006 Solution Consider building a new facility

Cause(s) Facility design susceptible to dust accumulation
Note This is not feasible at this time, but employ for future plant designs.
Assigned Criteria Failed
Due Status Identified

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Term long Cost $0.00

SO-0007 Solution Don't wait for regulatory agencies. Develop and apply standards internally.

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Cause(s) Regulatory gaps (OSHA, NFPA, IFC)
Note Proactively anticipate regulation and get in front of it. Conduct plant audits as if
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the regulations were in place.
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Assigned Criteria Passed
Due Status Identified
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Term short Cost $0.00

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SO-0008 Solution Completely clean the facility from top to bottom.

Cause(s) Tons of iron dust throughout facility
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Note The facility needs a complete cleaning. This needs to happen in conjunciton
with a more effective housekeeping effort. This will likely be a one-time effort
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because as sources for dust are found and eliminated, less dust will
accumulate.
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Assigned Criteria Passed

Due Status Identified
Term short Cost $0.00

SO-0009 Solution Clean up area before begining work

Cause(s) Iron dust on motor/elevator
Note Work areas need to be clean and free from debris. Proximity to flamable iron
dust was a major contributor to these two fatalities. Had the dust been removed
before work began, the incident may not have occurred.
Assigned Criteria Passed
Due Status Identified
Term short Cost $0.00

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 SO-0010 Solution Inspect the site for wiring hazards and fix.
Cause(s) Exposed wiring
Note Open J-boxes, exposed wiring, etc are not acceptable. All instances need to be
identified and fixed as soon as possible.
Assigned Criteria Passed
Due Status Identified
Term short Cost $0.00

SO-0011 Solution Complete an audit of the facility to identify improper grounding. Ensure
everything is properly grounded.
Cause(s) Motor not properly grounded
Note The facility and it's components need to be properly grounded.

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Assigned Criteria Passed
Due Status Identified
Term short Cost $0.00

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SO-0012 Solution Conduct PJHAs to identify risks. Wear appropriate PPE per risks identified.
Cause(s)
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Employees not protected
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Note All employees need to conduct PJHAs prior to begining a job. Make sure to
identify and mitigate risks associated with any job.
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Assigned Criteria Passed

Due Status Identified
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Term short Cost $0.00

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 Root Cause Analysis Report
2 Fatalities - Dust Explosion

Evidence
EV-0001 Evidence CSB Video "Iron in the Fire", 1/05/2012
Cause(s) 2 employees burned
Severity of burns = High
2 employees positioned near ignition point
Sufficient contact time
Iron dust from multiple sources
Iron dust ignited

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High temperatures
Combustible iron dust cloud near motor
Oxygen present

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Electric arc occurred (speculation)
Ignition occurred near motor
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Employees were investigating motor shutdown
Iron dust stirred up from motor/elevator surroundings
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Motor energized
Iron dust on motor/elevator
Motor/elevator vibrated
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Tons of iron dust throughout facility

System started up
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Vibration occurs upon start up

Dust handling system not completely sealed
Open conveyers
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Accumulated iron dust not cleaned up

Facility design susceptible to dust accumulation
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Regulatory gaps (OSHA, NFPA, IFC)

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Dust collection system frequently down

Location(s) CSB Website
Attachment(s)
Contributor
Type Other
Quality

EV-0002 Evidence CSB Hoeganaes Corporation Case Study

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 Cause(s) 2 employees burned
Severity of burns = High
2 employees positioned near ignition point
Sufficient contact time
Employees not protected
Iron dust ignited
High temperatures
FPC doesn't protect against large dust explosions
Employees wear Fire Protective Clothing (FPC)
Combustible iron dust cloud near motor
Oxygen present
Electric arc occurred (speculation)
Ignition occurred near motor
Employees were investigating motor shutdown
Iron dust stirred up from motor/elevator surroundings

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Exposed wiring
Motor not properly grounded
Motor energized
Iron dust on motor/elevator

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Motor/elevator vibrated
Tons of iron dust throughout facility
System started up ic
Vibration occurs upon start up
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Dust handling system not completely sealed
Open conveyers
Accumulated iron dust not cleaned up
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Facility design susceptible to dust accumulation

Regulatory gaps (OSHA, NFPA, IFC)
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Dust collection system frequently down

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Location(s) http://www.csb.gov/assets/document/CSB_Case_Study_Hoeganaes_Dec9_Final.pdf
Attachment(s)
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Contributor
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Type Document
Quality

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 Chart Key
N Dust handling system not
T Transitory completely sealed
N Non-Transitory

T Transitory Omission

N Non-Transitory Omission

Undefined Solutions
Chart Quality Alert
Identify and seal leaks in dust handling
Focal Point
system.
Evidence Notes

Solutions Tasks Criteria Pass Status Identified

Inspect the plant for contributors to
N Iron dust from multiple airborne dust through seal leaks. Rank
sources them, and work on eliminating the largest
contributors.

T Accumulated iron dust not

cleaned up N Open conveyers

Solutions
Implement housekeeping practices and Solutions
standards
Replace with closed conveyers, or modify
Criteria Pass Status Identified existing so they are enclosed
Housekeeping should become much easier Criteria Pass Status Identified
once the sources of dust are identified
No notes
and eliminated.

N Dust collection system

frequently down

Solutions
Conduct dyanamic analysis into dust
collection system outages

Criteria Pass Status Identified

N Iron dust on N Tons of iron dust
motor/elevator throughout facility The dust collection system has
reliability problems. Complete a
reliabilty assessment of the dust
collection system and develop a plan to
reduce the number and severity of
Solutions Solutions outages.

Clean up area before begining work
Criteria Pass Status Identified
Work areas need to be clean and free from
debris. Proximity to flamable iron dust
was a major contributor to these two
fatalities. Had the dust been removed
before work began, the incident may not
have occurred.
Completely clean the facility from top to
bottom.
Criteria Pass Status Identified
The facility needs a complete cleaning.
This needs to happen in conjunciton with
a more effective housekeeping effort.
This will likely be a one-time effort
because as sources for dust are found and N Facility design
eliminated, less dust will accumulate. susceptible to dust
accumulation

Solutions
Develop a plan to improve the dust
accumulation properties of the plant
design

Criteria Pass Status Identified

Utilize best practices for making a
facility resilient to dust accumulation.

Consider building a new facility

Criteria Fail Status Identified

This is not feasible at this time, but
employ for future plant designs.

N Combustible iron dust T Iron dust stirred up from

cloud near motor motor/elevator
surroundings

N Regulatory gaps (OSHA,

NFPA, IFC)
Terminated because:
N Oxygen present
Other causal paths more productive
END
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Solutions
Don't wait for regulatory agencies.
Develop and apply standards internally.
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Criteria Pass Status Identified

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Proactively anticipate regulation and get

in front of it. Conduct plant audits as
N Exposed wiring if the regulations were in place.
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T Iron dust ignited

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Solutions
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Inspect the site for wiring hazards and

fix.
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Terminated because:
Criteria Pass Status Identified T System started up
Other causal paths more productive
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Open J-boxes, exposed wiring, etc are not END

acceptable. All instances need to be
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identified and fixed as soon as possible.

T Motor/elevator vibrated

N Vibration occurs upon

start up
T Electric arc occurred N Motor not properly
(speculation) grounded

Solutions
Complete an audit of the facility to
T 2 employees burned identify improper grounding. Ensure
everything is properly grounded.

Criteria Pass Status Identified

The facility and it's components need to
be properly grounded.

Terminated because:
T Motor energized
Other causal paths more productive
END

Terminated because:
N Ignition occurred near
motor Other causal paths more productive
END

2 Fatalities
N 2 employees positioned
near ignition point

Terminated because:
N Employees were
investigating motor Other causal paths more productive
shutdown END

Terminated because:
N High temperatures
Other causal paths more productive
END

Terminated because:
N Sufficient contact time
Other causal paths more productive
END
N Severity of burns = High

Terminated because:
N FPC doesn't protect
against large dust Other causal paths more productive
explosions END

N Employees not protected

Terminated because:
N Employees wear Fire
Solutions Protective Clothing (FPC) Other causal paths more productive
Conduct PJHAs to identify risks. Wear END
appropriate PPE per risks identified.

Criteria Pass Status Identified

All employees need to conduct PJHAs prior
to begining a job. Make sure to identify
and mitigate risks associated with any
job.