 |
Explosion of
DeBruce
Grain
Elevator
Wichita, Kansas
8 June 1998 |
 |
| Grain Elevator Explosion Investigation Team (GEEIT) |
Below is an Executive Summary of the report on the DeBruce Grain Elevator explosion. The report in its entirety is available by contacting OSHA's regional headquarters in Kansas City at (816) 426-5861, or by writing to:
U.S. Department of Labor
Occupational Safety and Health Administration
1100 Main Street, Suite 800
Kansas City, MO 64105
Cost is $5 for a CD, or $100 for a printed copy. Checks or money orders (no cash) should be made payable to "Secretary of Labor."
Report on
Explosion of
DeBruce Grain
Elevator
Wichita, Kansas
8 June 1998
Commissioned by the
US Department of Labor
Occupational Safety and Health Administration
Grain Elevator Explosion Investigation Team
(GEEIT)
Vernon L. Grose, D.Sc., Editor
Report Placed in Final Electronic Format
By David K. McDonnell of OSHA in Cooperation with GEEIT
Report Table of Contents
DE BRUCE GRAIN ELEVATOR EXPLOSION
Wichita, Kansas
8 June 1998
Chapter 1 ENGAGEMENT OF INVESTIGATORY EXPERTISE
Grain Elevator Explosion History
National Academy of Sciences
Analysis of Previous Elevator Explosions
GEEIT (Grain Elevator Explosion Investigation Team)
Sponsorship Rationale
Chapter 2 EXECUTIVE SUMMARY OF EXPLOSION
Elevator Description
Location of Victims
Fatalities
Injured
On-Site Uninjured
Physical Damage
Rescue Factors
Probable Causation
Chapter 3 DE BRUCE GRAIN ELEVATOR HISTORY
Construction Evolution
Physical Dimensions and Characteristics
Headhouse
Offices
Elevator Equipment
Galleries
Silo Tunnels
Crossover Tunnels
Lean-To and Flat Storage
Continuous Gallery-Tunnel Belts
Grain Dust Control
Previous Accidents
Chapter 4 DE BRUCE MANAGEMENT ROLE IN EXPLOSION
DeBruce Intent in Elevator Acquisition
Revision of Operational Philosophy
Outsourcing
Dust Removal Equipment
Manual Dust Removal
Elimination of Functional Crews
Personnel Training Objectives
Criteria for Equipment Repair and Upkeep
Continuous Gallery-Tunnel Belt Operation
Chapter 5 DE BRUCE OPERATIONAL ROLE IN EXPLOSION
Worker Knowledge of Elevator Operation
Powdered Grain Explosive Comprehension
Powdered Grain Control -- Man and Machine
Comprehension of Grain Dust Ignition Sources
Techniques for Identification
Ignition Relationship to Explosion
Work Assignments and Indoctrination
"Team" Concept v. Functional Crews
Increased Production Rate
Operational Start-Stop Responsibility
Worker Cultural and Language Diversity
Safety Awareness
Hazard Identification and Countermeasures
Periodic Refresher Exposure
Emergency Response Plans and Drills
Chapter 6 ELEVATOR STATUS AT EXPLOSION'
Psychological Factors
"Monday Morning" Syndrome
Harvest Season Startup
Illegal Drug Use
Grain Handling Equipment
Drags, Belts, and Augers
Elevator Legs
Dust Collection Systems
Dust Collection Effectiveness
State of Elevator Cleanliness
Electrical Systems
Weather
Chapter 7 GRAIN ELEVATOR EXPLOSION FACTORS
Fuel (Grain in Powdered Form)
Oxidizer (air)
Fuel-and-Oxidizer Containment
Fuel Dispersion in Air
Ignition
Chapter 8 ANALYSIS OF EXPLOSION
Background
PHYSICAL Evidence
WITNESS Testimony
Process of Analysis
Seeking Explosion Initiation
Witness No. 1
Witness No. 2
Witness No. 3
Narrowing the Search
Combining Physical Evidence with Witness Testimony
Determining the Initiating Location
Locating the Enabling Mechanism
The Ignition Identification Process
Ignition Source
Layered Dust Accumulations
Blast Pathways of Progression
South Silo Array
Headhouse
North Silo Array
Possible Detonation
Quantitative Analysis of Damage
Evidentiary Foundation of Analysis
Rescue Operations
Compromise Between Rescue and Destroying Evidence
Loss of Evidence
Site Jurisdiction
Chapter 9 WITNESS TESTIMONY
Intelligence Sought
Silent Witnesses
Surviving Witnesses
Hospitalized Survivors
Injured But Not Hospitalized Survivors
Eyewitness Accounts
Chapter 10 TRENDS IN GRAIN HANDLING
Grain Storage v. Transportation
Movement -- Not Storage
Politics, Economics and Weather
Impact of Grain Handling
Utilizing Grain Dust as a Product
Chapter 11 ECONOMICS OF GRAIN DUST
USDA Grading of Grain
Bizarre Business
Hazardous, Not Just Economic
World Market Pricing
Chapter 12 ROLE OF WORKERS COMPENSATION
Forfeited Recourse
Kansas Version
Corporate Advantage
Disaster Prevention Motive
Chapter 13 INVESTIGATION LESSONS LEARNED
Not-Invented-Here (NIH) Factor
Fear of Litigation
Access Confusion
Photographic Recording
Greatest Lesson Learned
DeBruce Learned a Lesson, Too
Chapter 14 PREVENTION OF FUTURE ELEVATOR EXPLOSIONS
Preexisting Conditions
Allowable Grain Powder
Grain Dust Generation
Re-Distributed, Not Collected
Lack of Equipment Maintenance
Historic But Abandoned Dust Control
Post-Explosion Fuel Availability
Grain Transfer Entries
Headhouse Pollution
Explosive Fuel in Galleries
Impact of Cleaning in South Gallery
Tunnel Filthiness
Tunnel Impact on Explosion Initiation
APPENDICES
A. Scientific basis for the analysis of the explosion
B. Industrial Maintenance, Inc. solicited proposals
APPLICABLE FEDERAL REGULATIONS
REFERENCES
ACKNOWLEDGEMENTS
GEEIT MEMBERSHIP
Vernon L. Grose
Robert F. Hubbard
C. William Kauffman
Michael A. Polcyn
Ben F. Harrison
Thomas H. Seymour
Albert S. Townsend
List of Figures in the Report
DE BRUCE GRAIN ELEVATOR EXPLOSION
Wichita, Kansas
8 June 1998
Chapter 2 EXECUTIVE SUMMARY OF EXPLOSION
Figure 2-1:
|
Back to Top