Management system failures led to fatal dust explosion, board reports
The U.S. Chemical Safety and Hazard Investigation Board (CSB) has issued its final investigative report on a January 29, 2003, dust explosion at the West Pharmaceutical Services Inc., plant in Kinston, N.C.
West did not perform adequate engineering assessment of the use of powdered zinc stearate and polyethylene as anti-tack agents in the rubber batchoff process.
West engineering management systems did not ensure that relevant industrial fire safety standards were consulted.
West management systems for reviewing material safety data sheets did not identify combustible dust hazards.
The Kinston plant’s hazard communication program did not identify combustible dust hazards or make the workforce aware of such.
Develop/revise policies and procedures for new material safety reviews and safety reviews of engineering projects.
Ensure that its manufacturing facilities that generate combustible dusts meet the requirements of National Fire Protection Association (NFPA) Standard 654.
Improve hazard communication programs.
The blast killed six workers and injured 38 others, including two firefighters. The Kinston facility manufactured rubber drug-delivery components for such items as syringe plungers, septums and vial seals.
CSB determined that the fuel for the explosion was accumulated polyethylene dust above a suspended ceiling. Because of the extent of damage to the Kinston facility, it was not possible to definitively determine the event that dispersed the dust or what ignited it.
CSB determined the following root causes of the January 29 incident:
CSB has made substantive recommendations to West Pharmaceutical Services Inc., to:
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