Investigation Report: Vent Collection System Explosion, Cranston, Rhode Island, February 7, 2003 [open pdf - 3MB]
"The CSB investigation determined the following root causes: Technic did not conduct a process safety review to identify and evaluate the hazards associated with installing a vent collection system to handle the exhaust from multiple processes. Such a review would have likely included a process hazard analysis to identify and evaluate reactive chemical hazards. Competent reviewers would have evaluated and verified the design prior to and after installation; Technic did not identify and evaluate the hazards created by changes to facility processes and equipment (i.e., management of change). Significant changes made to the vent collection system were not envisioned in the original design and significantly deteriorated its performance. Such modifications should have been accompanied by a design and engineering review, a process hazard analysis, and before-and-after performance testing to ensure that the system was operating as intended. In addition, the following contributed to the incident and its consequences: Neither Technic nor CFD adequately planned for this type of emergency; and Technic did not have process and equipment integrity procedures or training to inspect or maintain the vent collection system." Key issues discussed include: incompatible chemical mixing, process safety review, management of change, preventive maintenance, and emergency planning and response.
Report no. 2003-08-I-RI
U.S. Chemical Safety and Hazard Investigation Board: http://www.csb.gov/