CSB cites need for training in fatal Reno explosion
The U.S. Chemical Safety and Hazard Investigation Board (CSB) has issued its report on the explosion that occurred at the Sierra Chemical Company`s Kean Canyon plant January 1998 in which four workers were killed and six injured.
CSB members found that the plant was deficient in many essential elements of process safety management. Plant workers had little formal training in safely handling materials used to manufacture explosives. The CSB also cited Sierra`s failure to provide procedure manuals and training in the workers` native language as a contributing factor. Most of the workers at the explosives plant were immigrants who spoke and read Spanish and had little or no understanding of the English language.
Key to the investigation, the CSB says, “was determining that the first of two explosions occurred in one of the buildings where explosive boosters were manufactured.”
The CSB concluded that “seconds later falling debris generated a second explosion in an explosives storage building farther south on the site.”
The CSB concurred with a seismic analysis conducted by Dr. Kenneth Smith of the University of Nevada at Reno “that confirmed the location of the original blast. This analysis unambiguously determined the relative distance between blast centers and that the northern of the two explosions occurred first.”
Sierra had said that the initial blast came from the explosives storage building. The CSB discounted this version on the bases of seismic analysis, debris patterns, interviews with witnesses, and analysis of forensic evidence.
The blast most likely occurred, the CSB said, “when a worker left melted explosive materials in a mixing pot by mistake over-night. When the mixing pot was turned on the next morning, its blade most likely hit solidified explosives that triggered the explosion.”
The CSB cited also poor regulatory oversight as a contributing factor to the plant`s unsatisfactory safety conditions.
The CSB recommended the following:
Nevada`s Occupational Safety and Health Enforcement Section, which enforces federal safety regulations, increase the frequency of safety inspections. Governor Bob Miller signed an executive order on June 10, 1998, mandating safety inspections of explosives manufacturing facilities at least twice a year.
The Department of Defense, which sells reclaimed, demilitarized explosives materials to plants like Sierra, develop ways to eliminate hazardous foreign materials from the reclaimed explosives sold.
An independent federal agency, the CSB is charged with ensuring worker and public safety by preventing or minimizing the effects of chemical accidents. The full text of the Sierra Chemical Company`s Kean Canyon plant report is available on the CSB web site at http://www.chemsafety.gov. n