CSB Recommendations Deficient-Flash Fire Hazards
on 02 October, 2009

John reports on the findings and recommendations of the Chemical Safety Board (CSB) after their final investigation report from September 24, 2009 on the dust explosion at Imperial Sugar Refinary.

Many stakeholders were anxious to hear the Chemical Safety Board (CSB) key findings and recommendations in the September 24, 2009 release of the final investigation report on the catastrophic dust explosion at Imperial Sugar Refinery. The CSB made five key recommendations with included adherence to NFPA combustible dust standards, comprehensive housekeeping, hazard communication training, emergency response, and that Imperial Sugar implement corrective actions in accordance with best engineering practices referenced in the NFPA standards. These recommendations were not solely directed at Imperial Sugar but the entire industrial sector that handles combustible particulate solids, which generate combustible dust. Yet CSB left out a key recommendation that workers don flame resistant clothing in the protection from flash fire severe burn injuries.

CSB Dust Hazard Study

In 2006 CSB concluded a Dust Hazard Study following a series of catastrophic high consequence dust explosions that occurred in 2003. The important safety recommendations of the study were forwarded to OSHA, which provided the agency a foundation in the formulation of the 2007 and 2008 reissued Combustible Dust National Emphasis Program (NEP). Additionally, following the Imperial Sugar Refinery explosion, the House Education and Labor Committee drafted a combustible dust bill utilizing the CSB Dust Hazard Study recommendations as the framework of the bill. Currently OSHA is drafting a general industry combustible dust regulation, which also is utilizing the CSB Dust Hazard Study recommendations as guidance.

All the recommendations from the Chemical Safety Board prompting action addressing combustible dust hazards in the industrial workplace is great and long overdue yet many layers of protection have been overlooked in the recommendations. This was especially evident when the data from the Dust Hazard Study only recognizes that 281 incidents occurred from 1980-2005, when in reality the incidents are ten times that many. For example, in 2008, the Combustible Dust Policy Institute discovered through media accounts, there were over 150 incidents in the manufacturing, non-manufacturing, and utility sectors. Probability of occurrence is an important element in obtaining an understanding of the complex issue of combustible dust.

For instance, the OSHA Combustible Dust NEP lists several dozen manufacturing national industries (NAICS) that have the potential or have a high risk in experiencing combustible dust incidents. Yet over 50% of national industries that had combustible dust related fires and explosions in 2008 were not listed as target industries (NAICS). Not to be picking on the paper subsector but to use as an example to illustrate a point, it's national industries (NAICS)are absent from the Dust NEP. On a global perspective amongst our international trading partners, an April 2009 dust explosion at a South African paper printing plant resulted in 14 fatalities and dozen of injuries from burns. This incident highlights that paper dust has a high consequence and potential for combustible dust fires and explosions.

Importance of PPE

Understanding probability of occurrence and severity of consequence is only one important aspect in addressing combustible dust hazards in the industrial workplace. Layers of protection are derived from administrative controls and best engineering practices with the final layer, personnel protection equipment (PPE). The Chemical Safety Board overlooked PPE in the recommendations following the key findings of the Imperial Sugar Refinery dust explosion. For instance the April 23, 2008 Chatham Emergency Management Agency, After Action Report mentions that 36 persons were injured and transported to Memorial hospital in Savannah, GA; 14 of those were non life-threatening injuries. Eventually a total of 20 victims were relocated to the Joseph M. Still Burn Center at Doctors Hospital in Augusta, Georgia with life threatening burn injuries.

Video: Doctors Hospital: Joseph M. Still Burn Center from Doctors Hospital on Vimeo.

Traumatic Burn Injuries

In a Burn Care Commentary time-line of the events following the dust explosion, the Joseph M. Still Burn Center highlights that the victims had," thermal burn injuries ranging from 5% Total Body Surface Area (TBSA) damage, treatable onsite and in area Emergency Departments, to 95% TBSA— critical burn damage that in most cases is not survivable." The Combustible Dust Policy Institute believes that if the workers had worn personnel protection equipment in the donning of flame resistant clothing (FRC), the Total Body Surface Area (TBSA) damage would of been less severe. Without FRC once a fireball makes contact with conventional clothing, the clothing ignites causing even more severe burns than the original flame.

A news account of a worker that succumbed to his burns at the Joseph M. Still Burn Center a week following the dust explosion indicated he had third degree burns on more than 80% of his body. Of the 20 workers that were admitted to the burn center, six (30%) did not survive due to the severity of their burn injuries. Malcolm Frazier, 47, of Savannah, a floor manager at the plant, with burns covering 85 percent of his body was the last one to succumb on August 22, 2008. Malcolm fought a brave fight hanging on for over seven months while his parents Richard and Hattie Frazier vigilantly stood by, encouraging him to persevere.

Burn Injury Studies

Chances of survival after life threatening burn injuries diminish rapidly in accordance with one's age group. In a 1991-1993 study conducted by the American Burn Association, results indicated Total Body Surface Area (TBSA) damage is a key survival factor for burn victims based on the age of the victim. For instance chances in survival of a victim in the 40-49 age group with over 75% TBSA is 30% versus 60% survivability for the 20-29 age group

Lawrence Manker Jr, 20, in the latter group was the last Imperial Sugar burn patient to be released from the burn center in October 2008. Lawrence, like Malcolm had burns to over 85% of his body. To assist the healing process, doctors medically induced him into a coma for six months so they could treat the severe burns. Studies have shown that burns to over 75% of the body can occur easily from the ignition and continued burning of conventional clothing versus workers that don FRC, which do not continue to burn when exposed to a flame source.

Flame Resistant Clothing in Industry

Workers in industries such as the petroleum, petrochemical, and chemical sectors where flash fire hazards also are present, already are donning flame resistant clothing in adherence with the requirements of proper personnel protection equipment. There is a disconnect in the USA where many governmental agencies, legislative officials, trade associations, professional organizations, and numerous other stakeholders are not aware that a dust explosion is a propagating explosion like a vapor cloud explosion which occurred at the BP Texas City Refinery in 2005. Both explosions have the devastating effects of overpressure, thermal radiation, and ensuing projectiles.

Reviewing the OSHA NEP's for combustible dust and Process Hazard Management (PSM), OSHA management recommends that CHSO's (inspectors) wear flame resistant clothing when conducting inspections at facilities where flash fire hazards are present. Ironically after over 55% of the victims from the Imperial Sugar explosion sustained life threatening burn injuries that were admitted to the Joseph M. Still Burn Center, the Chemical Safety Board does not include a sixth recommendation that flame resistant clothing be worn in potentially combustible dust explosive environments.


The only reason I can think that this recommendation was not included was due to the current litigation with millions of dollars at stake in potential compensation of all the burn victim survivors and families of the deceased. CSB must maintain neutrality and maintain impartiality in not placing blame. Including this important yet vital recommendation would of enhanced the plaintiffs case and been a damaging blow to the defendants. In all fairness, Imperial Sugar Refinery employees are now wearing FRC's in addtion to state of the art best engineering practices that CEO John Sheptor has implemented in the reconstruction efforts since the February 7, 2008 explosion.

An OSHA combustible dust standard is long overdue for general industry. In the past six years there's only been a handful of dedicated career governmental employees and legislators directing this much needed occupational health and safety policy. Last Thursday at the Hilton Savannah Desoto on East Liberty Street was a monumental and historical event where the CSB provided much needed recommendations to Imperial Sugar and the entire industry.

These recommendations will validate OSHA's current combustible dust rulemaking process. But that is where the problem arises, especially when all layers of protections are lacking, but must be considered in preventing future fatalities, severe injuries, and devastating economic damage. Personnel protection equipment in FRC's is just as important as housekeeping, training, emergency response, and NFPA best engineering practices. We owe it to Imperial Sugar Refinery explosion victims, survivors and families to get it right in the combustible dust rulemaking process so as to prevent and minimize future catastrophic occurrences.


CSB Imperial Sugar Accident Investigation Report
Chatham Emergency Management Agency After Action Report

Joseph M. Still Burn Center Burn Care Commentary
Flame Resistant Clothing Studies

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